POLICY & PROCEDURE MANUAL

Table of Contents (December 2014)

Note: (A) placed after policy number indicates Appendix

(F) placed after policy number indicates Form

(P) placed after policy number indicates Procedure

(S) placed after policy number indicates Sample Form Letter

SECTION 1000 – 1999: GOVERNANCE

See Prairie North Regional Health Authority Governance Manual

SECTION 2000 – 3499: FINANCE AND ASSET MANAGEMENT

Finance (2000 – 2299)

Accounting for PNRHA – Sponsored Educational Sessions ...............................2224

Accounting for PNRHA – Sponsored Educational Sessions Procedure ..............2224(P)

Cash Receipts Handling .......................................................................................2102

Cash Receipts Handling Procedure ......................................................................2102(P)

Charitable Donations ...........................................................................................2110

Donation Advice Form ............................................................................2110(F)

Collection of Fees – Long Term Care ..................................................................2106

Corporate Purchasing Cards ................................................................................2222

Acknowledgement and Responsibility of Purchasing Cardholder ..........Appendix A

Request For Purchasing Card...................................................................2222(F1)

Reconciliation of Purchasing Card Statement .........................................2222(F2)

Ethical Resource Allocation ................................................................................2005

Ethical Resource Allocation Procedure ...............................................................2005(P)

Ethics-Based Priority Analysis Tool ........................................................Appendix A

Expenditure Cycle Management ..........................................................................2151

Expense Claim Procedure ....................................................................................2223(P)

Fraudulent or Dishonest Conduct & Whistleblower Policy Statement ...............2050

General Ledger Management ...............................................................................2152

Inventory Management ........................................................................................2153

Inventory Management Procedure .......................................................................2153(P)

Investments ..........................................................................................................2105

Long Term Care Resident Trust Accounts ..........................................................2104

Markup on Sales ..................................................................................................2221

Operating Budget .................................................................................................2201

Operations Budgeting Procedure .........................................................................2201(P)

Petty Cash Funds..................................................................................................2101

Purchasing/Payment Authorization .....................................................................2220

Revenue Cycle Management ...............................................................................2150

Revenue Recognition – Services & Supplies to Clients ......................................2103

Staffing Budget Changes .....................................................................................2202

Staffing Budget Changes Procedure ....................................................................2202(P)

PNRHA Budget Change Form.................................................................2202(F1)

Staffing Worksheet ..................................................................................2202(F2)

Variance Reporting ..............................................................................................2210

Variance Reporting Template .................................................................2210(F)

Accounting (2300 - 2599) Collection of Accounts Receivable – Clients ......................................................2304

Client Accounts 60 Day Form Letter .......................................................2304(S1)

Client Accounts 90 Day Form Letter .......................................................2304(S2)

Manual Cheque Control .......................................................................................2310

Asset Management (2600 – 2799) Capital Assets and Depreciation ..........................................................................2604

Capital Technology and Minor Equipment Budgeting ........................................2605

Capital and Minor Equipment Purchase Brief Form ...............................2605(F)

Materials Management (2800 – 2999) Dress Code ...........................................................................................................2801

Large Volume Printing and Copying ...................................................................2810

Large Volume Printing and Copying Procedure ..................................................2810(P)

Transportation of Soiled and Sterilized Medical Devices ...................................2811

Transportation of Soiled and Sterilized Medical Devices Procedure ..................2811(P)

Medical Device Tracking Form ...............................................................2811(F)

SECTION 3500 – 3999: CLIENT SERVICES

Admitting (3500 – 3699)

Billing/AR (3700 – 3999)

SECTION 4000 – 4999: CAPITAL ASSET MANAGEMENT

Capital Planning (4000 – 4100)

Construction (4101 – 4200)

Maintenance (4201 – 4300)

SECTION 5000 – 5999: PAYROLL & SCHEDULING

Daily Flow Sheet Requirements – Employee & Manager ...................................5000

Daily Flow Sheet Requirements Procedure – Employee & Manager..................5000(P)

Daily Flow Sheet – What/What Not To Include ..................................................5001

Daily Flow Sheet – What/What Not To Include Procedure ................................5001(P)

Direct Deposit/Manual Cheque............................................................................5003

Direct Deposit/Manual Cheque Procedure ..........................................................5003(P)

Employee Move From One Union To Another Union .......................................5006

Employee Move From One Union To Another Union Procedure .......................5006(P)

Out Of Schedule Payment Processing .................................................................5004

Out Of Schedule Payment Processing Procedure ................................................5004(P)

Request For Leave Forms ....................................................................................5002

Request For Leave Forms Procedure ...................................................................5002(P)

Time In Lieu (TIL) Payouts .................................................................................5005

Time In Lieu (TIL) Payouts Procedure ................................................................5005(P)

SECTION 6000 – 6999: HUMAN RESOURCES & LABOUR RELATIONS

Labour Relations (6000 – 6300)

Code of Conduct & Ethics ...................................................................................6002

Code of Conduct & Ethics Procedure ..................................................................6002(P)

Confidentiality .....................................................................................................6004

Oath of Confidentiality ............................................................................Appendix A

Confidentiality Procedure ....................................................................................6004(P)

Conflict of Interest ...............................................................................................6005

Conflict of Interest Procedure ..............................................................................6005(P)

Approval for Outside Employment ..........................................................Appendix A

Criminal Record Screening ..................................................................................6000

Criminal Record Screening Procedure .................................................................6000(P)

Harassment and/or Abuse ....................................................................................6008

Harassment and or Abuse Procedure ...................................................................6008(P)

Harassment Complaint Form ...................................................................Appendix A

Harassment Assessment Checklist ...........................................................Appendix B

Harassment Investigation Checklist .........................................................Appendix C

Investigation of Complaints – Personnel .............................................................6003

Investigation of Complaints – Personnel Procedure ............................................6003(P)

Performance Review – Coaching for Success .....................................................6001

Coaching for Success Framework ...........................................................Appendix A

PNRH Customer Engagement and Service Expectations Framework ....Appendix B

Probationary and Trial Periods ............................................................................6006

Probationary and Trial Periods Procedure ...........................................................6006(P)

Probation or Trial Period Review Form...................................................6006(F)

Progressive Discipline .........................................................................................6007

Progressive Discipline Procedure ........................................................................6007(P)

Human Resources (6301 – 6599) Ability Management: Standardized Medical Certificate ....................................6308

Medical Certificate...................................................................................Appendix A

Annual Influenza Prevention Strategy .................................................................6322

Annual Influenza Prevention Strategy Procedure ................................................6322(P)

Employee “Immunize or Mask” Declaration ...........................................Appendix A

Attendance Support Policy ..................................................................................6303

Attendance Support Procedure ............................................................................6303(P)

Confirmation of Request For sick Time ..................................................Appendix A

Attendance Support Program Pamphlet ...................................................Appendix B

Medical Certificate...................................................................................Appendix C

Authorization to Immunize Employees of PNHR ...............................................6311

Authorization to Provide Immunizations & Manage Anaphylaxis ..........Appendix A

Authorization to Immunize Employees of PNHR Procedure ..............................6311(P)

Casual Dress Policy .............................................................................................6307

Cellular Phone/Portable Electronics Policy .........................................................6314

Cellular Phone/Portable Electronics Procedure ...................................................6314(P)

Committees ..........................................................................................................6301

Committees Procedure .........................................................................................6301(P)

Conflict Resolution ..............................................................................................6325

Conflict Resolution Procedure .............................................................................6325(P)

Dress Code ...........................................................................................................6306

Dress Code Procedure ..........................................................................................6306(P)

Employee Immunization Program .......................................................................6310

Recommended Assessment and Vaccinations for all Employees ............Appendix A

Pneumococcal Vaccination ......................................................................Appendix B

Employee Immunization Program Procedure ......................................................6310(P)

Current Authorization to Immunize Employees ......................................Appendix C

Employee Tuberculosis Screening .......................................................................6312

Employee Tuberculosis Screening .......................................................................6312(P)

Employment of Relatives .....................................................................................6313

Employment of Relatives Procedure ...................................................................6313(P)

Exit Interviews .....................................................................................................6316

Exit Interviews Form ...............................................................................6316(F)

Exit Interviews Procedure ....................................................................................6316)P)

Extreme Weather Attendance ..............................................................................6315

Extreme Weather Attendance Procedure .............................................................6315(P)

First Nation Liaison Worker ................................................................................6327

Consent For Liaison Services ..................................................................Appendix A

First Nation Liaison Worker Procedure ...............................................................6327(P)

Healthy Food Policy (See Community Health Section, Policy #17501)

Influenza Immunization or Mask Policy..............................................................6329

Job Descriptions – Development & Maintenance ...............................................6317

Job Descriptions – Development & Maintenance Procedure ..............................6317(P)

Long Service Recognition....................................................................................6302

Long Service Recognition Procedure ..................................................................6302(P)

Employee and Physician Long Service Awards Program .......................Appendix A

Personal Property Damage ...................................................................................6320

Notice Of Claim Form .............................................................................6320(F)

Personal Property Damage Procedure .................................................................6320(P)

Personnel Files – Retention & Destruction – Terminated Employees ................6324

Photo Identification ..............................................................................................6319

Photo Identification Procedure ............................................................................6319(P)

Photograph Guidelines for Photo Identification ......................................Appendix A

Regional Orientation – Mandatory .....................................................................6305

Regional Orientation Procedure ..........................................................................6305(P)

Representative Workforce ...................................................................................6309

Representative Workforce Procedure ..................................................................6309(P)

Request For Payment Of Professional Fees .........................................................6318

Request For Payment Of Professional Fees Procedure........................................6318(P)

Request For Payment Of Professional Fees Form ...................................6318(F)

Retirement Gifts ...................................................................................................6304

Retirement Gifts Procedure..................................................................................6304(P)

Sick Leave – Call In .............................................................................................6321

Sick Leave – Call In Procedure ...........................................................................6321(P)

Time in Lieu (TIL) Payouts .................................................................................6326

Time in Lieu (TIL) Payouts Procedure ................................................................6326(P)

Tobacco Reduction Policy/Procedure – Tobacco & Smoke-Free Property (See Community

Health Section, Policy #17502)

Vacation Carry Over and Vacation Payout ..........................................................6323

Vacation Carry Over and Vacation Payout Procedure ........................................6323(P)

Education (6600 – 6650)

Education Mandatory ...........................................................................................6600

Mandatory Education List........................................................................Appendix A

Education Mandatory Procedure ..........................................................................6600(P)

Education Personal Preference ............................................................................6602

Education Personal Preference Procedure ...........................................................6602(P)

Education Request Form ..........................................................................Appendix B

Financial Assistance Evaluation Guide ...................................................Appendix C

Staff Development Workshop Evaluation ...............................................Appendix D

Education Position Enhancement ........................................................................6601

Education Position Enhancement Procedure .......................................................6601(P)

Education Request Form ..........................................................................Appendix B

Financial Assistance Evaluation Guide ...................................................Appendix C

Staff Development Workshop Evaluation ...............................................Appendix D

Education – Train the Trainer ..............................................................................6603

Education – Train the Trainer Procedure .............................................................6603(P)

Mentoring New Grads..........................................................................................6604

Mentoring New Grads Procedure ........................................................................6604(P)

PNRHA Supernumerary Mentorship Professional Development

Fund – Application ..............................................................................Appendix A

Volunteer & Spiritual Services (6950 – 6999)

Philosophy of Spiritual Services & Management ................................................6958

Philosophy of Volunteer Involvement & Management .......................................6950

Philosophy of Volunteer Involvement & Management Procedure ......................6950(P)

Screening for Volunteer Placement .....................................................................6952

Screening for Volunteer Placement Procedure ....................................................6952(P)

Volunteer Enrolment Form ......................................................................Appendix A

Group Volunteer Form .............................................................................Appendix B

Volunteer Definition & Registration ...................................................................6951

Volunteer Definition & Registration Procedure ..................................................6951(P)

Volunteer Enrolment Form ......................................................................Appendix A

Volunteer Orientation & Education .....................................................................6954

Volunteer Orientation & Education Procedure ....................................................6954(P)

Volunteer Recognition .........................................................................................6956

Volunteer Recognition Procedure ........................................................................6956(P)

Volunteer Services Insurance Coverage ..............................................................6953

Volunteer Services Insurance Coverage Procedure .............................................6953(P)

Volunteer/Staff Relations.....................................................................................6957

Volunteer/Staff Relations Procedure ...................................................................6957(P)

Volunteer Supervision & Monitoring ..................................................................6955

Volunteer Supervision & Monitoring Procedure .................................................6955(P)

Volunteer Enrolment Form ......................................................................Appendix A

SECTION 7000 – 7499: RISK MANAGEMENT

Occurrence Reporting (7000 – 7100) Client Concern Handling .....................................................................................7001

Client Concern Handling Flowchart ........................................................Appendix A

Concern From Client Involving Physician ..............................................Appendix B

Client Concern Handling Procedure ....................................................................7001(P)

Record of Concern Handling ...................................................................Appendix C

Client Occurrence/Safety Reporting ....................................................................7000

Client Occurrence/Safety Report .............................................................Appendix A

Lab Client Occurrence/Safety Report .....................................................Appendix B

Client Occurrence/Safety Reporting Procedure ...................................................7000(P)

Instructions for Completing Client Occurrence/Safety Report ................Appendix C

Disclosure of Adverse Health Events ..................................................................7002

Disclosure of Adverse Health Events Procedure .................................................7002(P)

Accessing Client Services ........................................................................Appendix A

Expression of Regret ................................................................................Appendix B

Escalation of Unresolved and Urgent Patient and Staff Safety Issues .................7003

Escalation of Unresolved and Urgent Patient and Staff Safety

Issues Procedure..............................................................................................7003(P)

Escalation of Unresolved & Urgent Patient & Staff Safety Issues Form 7003(F)

Critical Incident Reporting (7101 – 7200) Critical Incident Review ......................................................................................7101

Critical Incident Review Procedure .....................................................................7101(P)

Saskatchewan Critical Incident Reporting Guideline, 2004 ....................Appendix A

Critical Incident Review – Follow-up..................................................................7102

Critical Incident Review – Follow-up Procedure ................................................7102(P)

PNHR Critical Incident Recommendations Report .................................Appendix A

Risk Management (7201 – 7300)

Checking Bath Water Temperature .....................................................................7202

Checking Bath Water Temperature Procedure ....................................................7202(P)

Water Temperature Log ...........................................................................Appendix A

Cleaning and Disinfection of Non-critical Medical Equipment or Devices ........7207

Glossary of Terms ....................................................................................Appendix A

Decision Chart for Cleaning and Disinfection .........................................Appendix B

Client Care Equipment Cleaning Guidelines in Rehab............................Appendix C

Acute Care – Health Care Provider Responsible for Cleaning

and Disinfection ...................................................................................Appendix D

LTC – Health Care Provider Responsible for Cleaning

and Disinfection ..................................................................................Appendix E

Cleaning and Disinfection of Non-critical Medical Equipment or

Devices Procedure ..........................................................................................7207(P)

Infection Prevention and Control Program ..........................................................7206

Infection Prevention and Control Program Procedure .........................................7206(P)

Medication Reconciliation ...................................................................................7205

Medication Reconciliation Procedure ..................................................................7205(P)

Medication Reconciliation Process Flow Map ........................................Appendix A

Preadmission Medication List/Physician Order Form .............................Appendix B

Discharge Medication Plan & Prescription Form ....................................Appendix C

Medication Reconciliation Audit Form ...................................................Appendix D

Safe Medication – Do Not Use Abbreviations, Symbols and Dose

Designations .....................................................................................................7203

Do Not Use List .......................................................................................Appendix A

Safe Mediation – Do Not Use Abbreviations, Symbols and Dose

Designations Procedure ...................................................................................7203(P)

Safety Alerts.........................................................................................................7201

Safer Practice Notice Stat ........................................................................Appendix A

Safer Practice Notice................................................................................Appendix B

Safety Alerts Procedure .......................................................................................7201(P)

Transfer of Patient Care Information ...................................................................7208

Transfer of Patient Care Information Procedure ..................................................7208(P)

Patient Transfer Checklist ........................................................................Appendix A

Two Patient Identifiers .........................................................................................7204

Two Patient Identifiers Procedure - PMP ............................................................7204(P1)

Two Patient Identifiers Procedure – Dental Health Educator ..............................7204(P2)

Two Patient Identifiers Procedure – PHNs ..........................................................7204(P3)

Two Patient Identifiers Procedure – SHNB .........................................................7204(P4)

Two Patient Identifiers Procedure – Nurse Practitioners PHC ............................7204(P5)

Two Patient Identifiers Procedure – Home Care .................................................7204(P6)

Two Patient Identifiers Procedure – LTC ............................................................7204(P7)

Two Patient identifiers Procedure – Acute Care ..................................................7204(P8)

SECTION 7500 – 7999: EMERGENCY PREPAREDNESS

General (7500 – 7600) After Action Reporting ........................................................................................7504

After Action Reporting Procedure .......................................................................7504(P)

After Action Report – Basic Emergency Preparedness ...........................Appendix A

After Action Report – Health Incident Command ...................................Appendix B

Emergency Preparedness – Annual Review Of The Plan ....................................7502

Emergency Preparedness – Annual Review Of The Plan Procedure ..................7502(P)

Emergency Preparedness – Objectives ................................................................7500

Emergency Preparedness – Plans.........................................................................7501

Emergency Preparedness – Plans Procedure .......................................................7501(P)

Emergency Preparedness – Response Readiness .................................................7503

Emergency Preparedness – Response Readiness Procedure ...............................7503(P)

Fire Drills .............................................................................................................7505

Fire Drills Procedure ............................................................................................7505(P)

Regional Fire Drill Report .......................................................................Appendix A

Pandemic (7601 – 7650)

SECTION 8000 – 8999: PATIENT RIGHTS, PRIVACY PROTECTION

HIPA (8101 – 8200) Access/Amendment to Personal Health Information ...........................................8104

Request For Access To Personal Health Information Form ....................8104(F)

Consent for Collection, Use and Disclosure of Personal Health Information .....8103

Consent for Disclosure of Personal Health Information Form ................8103(F)

Disclosure of Personal Health Information to Law Enforcement Agencies ........8109

Disclosure Outside the Circle of Care .................................................................8106

External Electronic Access ..................................................................................8112

Guidelines on Facsimile Transmission Security ..................................................8108

Guidelines on Facsimile Transmission Security Procedure .................................8108(P)

Information Protection .........................................................................................8101

Information Protection Procedure ........................................................................8101(P)

Informing Individuals ..........................................................................................8102

Mandatory Reporting of Gunshots and Stab Wounds .........................................8114

Mandatory Reporting of Gunshots and Stab Wounds Procedure ........................8114(P)

Mandatory Reporting of Gunshot and Stab Wounds Form .....................8114(F)

Privacy Concern Handling ...................................................................................8111

Protection of Quality of Improvement Information .............................................8113

Retention/Destruction of Records Containing Personal Health Information ......8110

Sole Trustee Services and Access ........................................................................8107

Use and Disclosure for Provision of Care (Circle of Care) .................................8105

Informed Consent (8201 – 8300)

Ethics (8301 – 8400) Client Abuse and Neglect ....................................................................................8305

Strategies for Prevention ..........................................................................Appendix A

Indicators of Abuse and Neglect ..............................................................Appendix B

Ethics Committee Terms of Reference ................................................................8303

Health Care Directive ..........................................................................................8301

Health Care Directive Brochure ...............................................................Appendix A

Health Care Directive Form .....................................................................8301(F)

Health Ethics Consultation ..................................................................................8302

The Health Ethics Consultation Brochure ..............................................Appendix A

Health Ethics Consultation Procedure .................................................................8302(P)

Health Ethics Consultation Intake and Consultation Notes .....................Appendix B

Core Competencies For Ethics Consultation ...........................................Appendix C

SECTION 9000 – 9999: INFORMATION MANAGEMENT

General Information (9000 – 9099)

Policy Development ............................................................................................9000

Policy Development Procedure ...........................................................................9000(P)

Existing Sections From Table of Contents ..............................................Appendix A

Health Information (9100 – 9999)

Medical Chart Completion – Rules & Regulations .............................................9100

Details Included In Delivery Note/Discharge Summary For Obstetrics .Appendix A

Medical Chart Completion – Rules & Regulations Procedure ............................9100(P)

SECTION 10000 – 10499: OCCUPATIONAL HEALTH & SAFETY

See Occupational Health & Safety Policy and Procedure Manual

SECTION 10500 – 10999: GENERAL PATIENT CARE

General Patient Care (10500 – 10899) Antimicrobial Stewardship - See Acute & Emergency Services No. 12410/12410(P)

Braden Scale, Braden Q Scale – Pressure Ulcer Risk Assessment ......................10502

Braden Scale (Form 1 ..............................................................................10502(F1)

Braden Q Scale (Form 2) .........................................................................10502(F2)

Neonatal/Infant – Braden Q Scale (Form 3) ............................................10502(F3)

Braden Scale, Braden Q Scale – Pressure Ulcer Risk Assessment Procedure ....10502(P)

Central Venous Access Devices ..........................................................................10515

Central Venous Access Device – Short Term Catheters Procedure ....................10515(P1)

Cleaning and Disinfection of Non-critical Medical Equipment or Devices (See Risk

Management Section, Policy and Procedure 7207/707(P)

Client Assessment Pre-procedure (CAPP)...........................................................10518

Client Assessment Pre-procedure (CAPP) Procedure .........................................10518(P)

CAPP Medication Sheet ..........................................................................Appendix A

ASA/CAS Fasting Guidelines..................................................................Appendix B

Surgical Services CAPP Patient Education Handout...............................Appendix C

Client Assessment Pre-procedure (CAPP) Telephone Interview

(Day Surgery)...................................................................................................10519

Client Assessment Pre-procedure (CAPP) Telephone Interview Procedure

(Day Surgery)...................................................................................................10519(P)

Screening Tool for Pre-Admission Clinic Telephone Interview .............Appendix A

Diabetes Care – Hypoglycemia ...........................................................................10516

Diabetes Care – Hypoglycemia Procedure ..........................................................10516(P)

Implanted Vascular Access Device (IVAD) (Port) Procedure ............................10515(P2)

Central Venous Access Device – Tunneled Catheters Procedure .......................10515(P3)

Central Venous Access Device – Peripherally Inserted (PICC) ..........................10515(P4)

Daily Calibrations for the KoKo Spirometer .......................................................10505

Daily Calibrations for the KoKo Spirometer Procedure ......................................10505(P)

Deep Wound/Body Cavity Packing Documentation & Tracking ........................10507

Deep Wound/Body Cavity Packing Documentation & Tracking Procedure.......10507(P)

Enteral Tube Feeding – Continuous Delivery Method ........................................10509

Adult & Pediatric Standing Lab Orders for Enteral Feeding ...................Appendix A

Enteral Tube Feeding – Continuous Delivery Method Procedure .......................10509(P)

Enteral Tube Feeding – Intermittent Delivery Method........................................10510

Adult & Pediatric Standing Lab Orders for Enteral Feeding ...................Appendix A

Enteral Tube Feeding – Intermittent Delivery Method Procedure ......................10510(P)

Fall Prevention .....................................................................................................10513

Falls Prevention Procedure ..................................................................................10513(P)

Forced Vital Capacity (FVC) on the KoKo Spirometer ......................................10504

Forced Vital Capacity (FVC) on the KoKo Spirometer Procedure .....................10504(P)

Infusion Pumps ....................................................................................................10503

Infusions Pumps Procedure..................................................................................10503(P)

Infusion Pumps Certification Checklist ...................................................Appendix A

Plum A+ Infusion Pump Recertification Quiz .........................................Appendix B

Negative Pressure Wound Therapy – V.A.C. Dressing .......................................10508

Procedure For Obtaining V.A.C. Rental Unit ..........................................Appendix A

Pre-V.A.C. Therapy Data .........................................................................Appendix B

Negative Pressure Wound Therapy Physician’s Orders ..........................Appendix C

Form For Ordering V.A.C. Rental From Materials Management ...........Appendix D

V.A.C. Dressing Selection Guide ............................................................Appendix E

Negative Pressure Wound Therapy – V.A.C. Dressing Procedure ......................10508(P)

Nutritional Medication Pass (Med Pass)..............................................................10522

Nutritional Medication Pass (Med Pass) Procedure ............................................10522(P)

Pain Management.................................................................................................10500

Pain Management Guidelines – (Cognitively Well) ................................Appendix A

Comprehensive Pain Assessment ............................................................Appendix B

Pain Flow Sheet .......................................................................................Appendix C

Numerical Pain Rating Scale ...................................................................Appendix D

Understanding Your Pain Brochure .........................................................Appendix E

Pain Management Satisfaction Survey ....................................................Appendix F

Pet Visitation in Acute Care ................................................................................10512

Pet Visitation in Acute Care Procedure ...............................................................10512(P)

Reporting of a Child in Need of Protection/Intervention.....................................10521

Reporting of a Child in Need of Protection/Intervention Procedure ...................10521(P)

Ministry of Social Services Child Protection Offices ..............................Appendix A

First Nations Child & Family Services List .............................................Appendix B

Child Protection Services Information.....................................................Appendix C

Standards For Use Of Restraints ..........................................................................10501

Standards For Use Of Restraints Procedure .........................................................10501(P)

Individual Restraint Assessment Form ....................................................Appendix A

Clinical Decision Making Guide – Agitation/Aggression/Wandering ....Appendix B

Clinical Decision Making Guide – Falls ..................................................Appendix C

Individual Restraint Re-Assessment Form ..............................................Appendix D

Guidelines and Potential Risks For Use Of Restraints ............................Appendix E

Consent to Use of Restraints ....................................................................Appendix F

Restraint Monitoring Flow Sheet .............................................................Appendix G

List of Physical Restraints Used by PNHR..............................................Appendix H

Total Parenteral Nutrition – Central Line Infusion ..............................................10511

Total Parenteral Nutrition – Central Line Infusion Procedure .............................10511(P)

TPN Protocol ...........................................................................................Appendix A

Visiting Hours (excludes LTC) ............................................................................10520

Visiting Hours Procedure (excludes LTC) ..........................................................10520(P)

Wound Care .........................................................................................................10514

Wound Care Procedure ........................................................................................10514(P)

Wound Care Assessment and Treatment .............................................................10506

Wound Care Assessment and Treatment Procedure ............................................10506(P)

Wound Photography, Clinical ..............................................................................10517

Wound Photography, Clinical Procedure ............................................................10517(P)

Consent For Clinical Wound Photography ..............................................Appendix A

Medication Management (10900 – 10999) Allergy & Intolerance/Sensitivity Information ....................................................10902

Allergy & Intolerance/Sensitivity Information Procedure ...................................10902(P)

Allergy & Intolerance/Sensitivity Record ...............................................Appendix A

Client Occurrence/Safety Report .............................................................Appendix B

Automatic Substitutions .......................................................................................10901

Approved Automatic Formulary Substitutions ........................................Appendix A

Automatic Substitutions Procedure......................................................................10901(P)

Look-alike/Sound-alike & Tallman Lettering Medications .................................10903

Look-alike/Sound-alike & Tallman Lettering Medications Procedure ...............10903(P)

High-Risk Medication ..............................................................................Appendix A

ISMP’s List of Confused Drug Names ....................................................Appendix B

Medication Orders ...............................................................................................10900

Medication Orders Procedure ..............................................................................10900(P)

Parenteral Drug Information Resource ................................................................10904

Parenteral Drug Information Resource Procedure ...............................................10904(P)

SECTION 11000 – 12999: ACUTE & EMERGENCY SERVICES

Medical (11000 – 11299) Administration of IV Therapy by LPNs ..............................................................11001

Administration of IV Therapy by LPNs Procedure .............................................11001(P)

Administration of Medications by LPNs .............................................................11002

Administration of Medications by LPNs Procedure ............................................11002(P)

Administration of Norepinephrine (Levophed, Levarterenol, Noradrenaline) ....11012

Administration of Norepinephrine (Levophed, Levarterenol, Noradrenaline)

Procedure .........................................................................................................11012(P)

Antibiotic Prophylaxis in Pre-operative Patients .................................................11020

Antibiotic Prophylaxis in Pre-operative Patients Procedure ................................11020(P)

Antimicrobial Stewardship - See Acute & Emergency Services No. 12410/12410(P)

Ceremonial Tobacco (Smudging Ceremony) ......................................................11026

Ceremonial Tobacco Procedure (Smudging Ceremony) .....................................11026(P)

Smudging Ceremony Information ...........................................................Appendix A

Cleaning and Disinfection of Non-critical Medical Equipment or Devices (See Risk

Management Section, Policy and Procedure 7207/7207(P)

Consent to Surgery, Diagnostic & Treatment ......................................................11006

Consent to Surgery, Diagnostic & Treatment Procedure.....................................11006(P)

Procedures Requiring Written Consent ...................................................Appendix A

Consent to Surgery, Diagnostic and Treatment Procedures Form ...........Appendix B

ER/Outpatient Narcotic Administration – Discharge Information ......................11005

Discharge Information Following Narcotic Administration ....................Appendix A

Governance of Patient Order Sets ........................................................................11024

Governance of Patient Order Sets Procedure .......................................................11024(P)

Order Set/Clinical Protocol Sign-off Form ..............................................Appendix A

Hair Removal in Pre-operative Patients ...............................................................11021

Hair Removal in Pre-operative Patients Procedure .............................................11021(P)

HIV Infected Woman in Labour in PNHR…Management of Mother

and Newborn ....................................................................................................11003

HIV Infected Woman in Labour in PNHR…Management of Mother

and Newborn Procedure ...................................................................................11003(P)

Orders for the HIV Infected Woman During Labour & Delivery ...........Appendix A

Orders for the Newborn Baby Greater than or Equal to 35 Weeks

Gestation ...............................................................................................Appendix B

Orders for the Newborn Baby Less than 35 Weeks Gestation ................Appendix C

Medication Package Form .......................................................................Appendix D

Interdisciplinary Rounds and Case Conferences in Management of Complex

Patients .............................................................................................................11008

Interdisciplinary Rounds and Case Conferences in Management of Complex

Patients Procedure ............................................................................................11008(P)

Intraosseous Infusion Vascular Access In Infants & Children ............................11009

Intraosseous Infusion Vascular Access In Infants & Children Procedure ...........11009(P)

Intravenous Management In Pediatric Patients ....................................................11013

Intravenous Management In Pediatric Patients Procedure ..................................11013(P)

Leaving Against Medical Advice ........................................................................11023

Leaving Against Medical Advice Procedure .......................................................11023(P)

Release Against Medical Advice .............................................................Appendix A

Licensed Practical Nurses (LPNs) Scope of Practice ..........................................11000

SALPN Position Statement on Advanced Practice .................................Appendix A

SALPN Position Statement on Assigning Care to Unregulated Care

Providers ..............................................................................................Appendix B

Management of Hypothermia ..............................................................................11014

Management of Hypothermia Procedure .............................................................11014(P)

Hypothermia Algorithm – Appendix A ...................................................Appendix A

Most Responsible Physician ................................................................................11010

Normothermia ......................................................................................................11022

Normothermia Procedure .....................................................................................11022(P)

Pediatric Sepsis Protocol......................................................................................11015

Pediatric Sepsis Protocol Procedure ....................................................................11015(P)

Regional Sepsis Protocol Pediatric Sepsis Alert ......................................Appendix A

MRSA Risk Factors .................................................................................Appendix B

Peri-operative Glucose Control............................................................................11019

Peri-operative Glucose Control Procedure ..........................................................11019(P)

Sepsis Protocol for Adults ...................................................................................11016

Sepsis Protocol for Adults Procedure ..................................................................11016(P)

Regional Sepsis Protocol Adult Sepsis Alert ...........................................Appendix A

MRSA Risk Factors .................................................................................Appendix B

Surgical Plume Scavenging During Electrosurgical Unit Use ............................11018

Surgical Plume Scavenging During Electrosurgical Unit Use Procedure ...........11018(P)

Example of Procedures Requiring an In-line Filter .................................Appendix A

Example of Procedures Requiring a Smoke Evacuator ...........................Appendix B

Telephone Advice by Registered Nurse ..............................................................11004

Venous Thromboembolism Prophylaxis (VTE) ..................................................11025

Venous Thromboembolism Prophylaxis (VTE) Procedure .................................11025(P)

VTE Risk and Suggested Prophylaxis for Surgical Patients ...................Appendix A

VTE Risk and Suggested Prophylaxis for Medical Patients ....................Appendix B

Preventing Deep Vein Thrombosis & Pulmonary Embolism Pamphlet ..Appendix C

Xarelto Patient Information .....................................................................Appendix D

4 Steps of Thromboprophylaxis ...............................................................Appendix E

Prevent Venous Thromboembolism ........................................................Appendix F

PNRHA VTE Prophylaxis Audit Tool ....................................................Appendix G

Chemotherapy (11300 – 11399)

Women and Maternal/Newborn Health (11400 – 11499) Ampicillin Administration in the Neonate ...........................................................11420

Ampicillin Administration in the Neonate Procedure .........................................11420(P)

Antimicrobial Stewardship - See Acute & Emergency Services No .12410/12410(P)

Baby Friendly – Family Friendly Strategies ........................................................11400

Baby Friendly - Family Friendly Strategies Procedure .......................................11400(P)

Bilirubin – Monitoring, Management of Hyperbilirubinemia .............................11405

Bilirubin – Monitoring, Management of Hyperbilirubinemia Procedure ............11405(P)

Breast Feeding Policy ..........................................................................................11401

Breast Feeding Procedure ....................................................................................11401(P)

Breast Pump Management ...................................................................................11417

Breast Pump Management Procedure ..................................................................11417(P)

Breech Vaginal Delivery Guidelines ...................................................................11431

Breech Vaginal Delivery Guidelines Procedure ..................................................11431(P)

Cefotaxime (Claforan) Administration in Neonate ..............................................11421

Cefotaxime (Claforan) Administration in Neonate Procedure ............................11421(P)

Cleaning and Disinfection of Non-critical Medical Equipment or Devices (See Risk

Management Section, Policy and Procedure 7207/7207(P)

Duratocin/Carbetocin, Administration Management ...........................................11427

Duratocin/Carbetocin, Administration Management Procedure..........................11427(P)

Family Centered Care of the Maternity Patient in the OR ...................................11430

Family Centered Care of the Maternity Patient in the OR Procedure .................11430(P)

Family Centered Care – Mother/Baby .................................................................11429

Family Centered Care – Mother/Baby Procedure ................................................11429(P)

Fetal Movement Counts .......................................................................................11410

Fetal Movement Counts Procedure ......................................................................11410(P)

Fetal Movement Count Chart ...................................................................Appendix A

Full Term Newborn Routine (Initial Care and Admission) .................................11409

Full Term Newborn Routine Procedure (Initial Care and Admission) ................11409(P)

MedCalc: Ballard Maturational Assessment of Gestational Age ...........Appendix A

Glucose Screening Newborn/Women’s Health Obstetrics ..................................11416

Algorithm for Screening Babies at Risk for Neonatal Hypoglycemia ....Appendix A

Glucose Screening Newborn/Women’s Health Obstetrics Procedure .................11416(P)

Group B Streptococcal Infection (GBS) ..............................................................11411

Group B Streptococcal Infection (GBS) Procedure .............................................11411(P)

Hyperstimulation Syndrome (Hypertonic/Tetanic Contraction) .........................11406

Hyperstimulation Syndrome Procedure (Hypertonic/Tetanic Contraction) ........11406(P)

In-Hospital Birth Universal Questionnaire ..........................................................11403

In-Hospital Birth Questionnaire Form .....................................................Appendix A

Induction/Augmentation of Labour & Cervical Ripening ...................................11428

Stripping of Membranes ..........................................................................Appendix A

Cervical Ripening Using a Foley Balloon Catheter .................................Appendix B

Vaginal Prostaglandin Administration .....................................................Appendix C1

Cervidil Administration As An Outpatient ..............................................Appendix C2

Amniotomy/Artificial Rupture of Membranes (ARM) ............................Appendix D

Oxytocin Infusion for Induction and Augmentation of Labour ...............Appendix E

Oxytocin Increment Tables – 10 Units/500 ml ........................................Appendix E1

Oxytocin Increment Tables – 10 Units/1000 ml ......................................Appendix E2

Oxytocin Increment Tables – 20 Units/1000 ml ......................................Appendix E3

Oxytocin Increment Tables (High Dose) – 10 Units/1000 ml .................Appendix E4

Oxytocin Increment Tables (High Dose) – 20 Units/1000 ml .................Appendix E5

Oxytocin Compatibility Chart..................................................................Appendix E6

General Information .................................................................................Appendix F

Algorithm for Cervical Ripening and Induction of Labour .....................Appendix G

Induction Booking Requisition ................................................................Appendix H

Guidelines for Induction Prioritization ....................................................Appendix I

Frequency of Documentation of Fetal Heart Contractions/Vital Signs ...Appendix J

Classification of Intrapartum EFM Tracings ...........................................Appendix K

Bishops Score Pre-Induction Cervical Score Table .................................Appendix L

Cervidil (How To)....................................................................................Appendix M

Cervidil Vaginal Insert Pamphlet.............................................................Appendix N1

Cervidil Vaginal Insert – Outpatient Information ....................................Appendix N2

Outpatient Telephone Assessment ...........................................................Appendix O

Fetal Movement Count Chart ...................................................................Appendix P

Induction/Augmentation of Labour & Cervical Ripening Procedure ..................11428(P)

Infant Feeding Plan ..............................................................................................11408

Infant Feeding Plan Procedure .............................................................................11408(P)

Infant Feeding Plan ..................................................................................Appendix A

Infant Sleeping Practises ......................................................................................11402

Safe Sleeping Tips ...................................................................................Appendix A

Magnesium Sulphate Administration for the Control of Gestational

Hypertension ....................................................................................................11426

Magnesium Sulphate Administration for the Control of Gestational

Hypertension Procedure ...................................................................................11426(P)

24 Hour Critical Care Flow Sheet ............................................................Appendix A

Maternal Mental Health .......................................................................................11425

Edinburgh Postnatal Depression Scale ....................................................Appendix A

Maternal Mental Health Procedure ......................................................................11425(P)

EPDS Screening & Care Guide ...............................................................Appendix B

Maternal/Newborn Transfer.................................................................................11443

Maternal/Newborn Transfer Procedure ...............................................................11443(P)

Newborn Transfer Record........................................................................Appendix A

Maternal Transfer Record ........................................................................Appendix B

Misoprostol (Cytotec), Administration & Management of ..................................11418

Misoprostol (Cytotec) Procedure, Administration & Management of ................11418(P)

Stomach Capacity of the Newborn ..........................................................Appendix A

Multiple Birth, Management of ...........................................................................11444

Multiple Birth, Management of Procedure ..........................................................11444(P)

Presentations ............................................................................................Appendix A

Neonatal Abstinence Syndrome (Drug Withdrawal) ...........................................11423

Neonatal Abstinence Syndrome Procedure (Drug Withdrawal) ..........................11423(P)

Neonatal Abstinence Syndrome Scoring .................................................Appendix A

Scoring Tool Interpretation ......................................................................Appendix B

Neonatal Screening (Metabolic and Endocrine Investigations) ...........................11404

Neonatal Screening Procedure (Metabolic and Endocrine Investigations) .........11404(P)

Reminder Card .........................................................................................Appendix A

Newborn Screening Pamphlet..................................................................Appendix B

Newborn Screening for HHH Syndrome .................................................Appendix C

Neonatal Sepsis ....................................................................................................11422

Neonatal Sepsis Procedure ...................................................................................11422(P)

Newborn Feeds ....................................................................................................11407

Stomach Capacity of the Newborn ..........................................................Appendix A

Newborn Feed Procedure .....................................................................................11407(P)

Newborn - Group B Streptococcus Infection, Management of ...........................11439

Newborn - Group B Streptococcus Infection, Management of Procedure ..........11439(P)

Newborn Head Circumference – Assessment Following an Assisted Birth

- Vacuum or Forceps .......................................................................................11438

Newborn Head Circumference – Assessment Following an Assisted Birth

- Vacuum or Forceps Procedure ......................................................................11438(P)

Neonatal GBS Disease Decision Tree .....................................................Appendix A

GBS Disease Pamphlet ............................................................................Appendix B

Newborn – Identification of .................................................................................11437

Newborn – Identification of Procedure................................................................11437(P)

Obstetric Incident Reporting Guidelines .............................................................11440

Obstetrical Incident Reporting Guidelines...............................................Appendix A

Obstetric Incident Reporting Guidelines Procedure ............................................11440(P)

Pain Management in Labour ................................................................................11435

Pain Management in Labour Procedure ...............................................................11435(P)

Pain Relief For Childbirth Pamphlet........................................................Appendix A

Photography/Video in Delivery, Management of ...............................................11442

Photography/Video in Delivery, Management of Procedure ...............................11442(P)

Postpartum Hemorrhage, Emergency Management In The Absence

of Physician ......................................................................................................11424

Postpartum Hemorrhage, Emergency Management In The Absence

of Physician Procedure ....................................................................................11424(P)

Degrees of Postpartum Hemorrhage ........................................................Appendix A

Medication Dosing Guidelines ................................................................Appendix B

Preterm Labor - Tocolytic Management of .........................................................11413

Preterm Labour Management Audit Tool ................................................Appendix E

Preterm Labour Audit Summary ..............................................................Appendix F

Preterm Labor - Tocolytic Management of Procedure ........................................11413(P)

Fetal Fibronectin Testing Requisition ......................................................Appendix A

Preterm Labour Decision Tree .................................................................Appendix B

Indomethacin Administration Protocol ....................................................Appendix C

Nifedipine Administration for Suppression of Preterm Labour ..............Appendix D

Preterm Rupture of Membranes ...........................................................................11432

Case Audit Tool: Preterm Rupture of Membranes ................................Appendix A

Preterm Rupture of Membranes Procedure ..........................................................11432(P)

Fetal Movement Count Chart ...................................................................Appendix B

Decision Tree Greater Than 34 Weeks ....................................................Appendix C

Decision Tree Less Than 34 Weeks .........................................................Appendix D

Privileging & Required Skills For GPs With Obstetrical Privileges ...................11433

Privileging & Required Skills For GPs With Obstetrical Privileges Procedure ..11433(P)

Guidelines for Obstetrical Consultation and Transfer of Care ................Appendix A

Criteria for Instrument Deliveries According to Station and Rotation ....Appendix B

Prolapsed Cord, Management of..........................................................................11441

Prolapsed Cord Procedure, Management of ........................................................11441(P)

Sponge Count/Needle Count – Vaginal Delivery ................................................11414

Sponge Count/Needle Count – Vaginal Delivery Procedure ...............................11414(P)

Staff Education – Breastfeeding (Mandatory) .....................................................11415

Staff Education – Breastfeeding (Mandatory) Procedure ....................................11415(P)

Surfactant – Newborn Administration of .............................................................11436

Surfactant – Newborn Administration of Procedure ...........................................11436(P)

Temperature Monitoring of the Newborn ............................................................11419

Temperature Monitoring of the Newborn Procedure ...........................................11419(P)

Umbilical Cord Blood Stem Cell Collection .......................................................11412

Umbilical Cord Blood Stem Cell Collection Procedure ......................................11412(P)

Vaginal Birth After Previous Caesarean Birth (VBAC) ......................................11434

Vaginal Birth After Previous Caesarean Birth (VBAC) Procedure.....................11434(P)

Patient Information VBAC ......................................................................Appendix A

Clinical Information Tool – Related To Informed Consent .....................Appendix B

Pediatrics (11500 – 11599)

Surgical (11600 – 11699)

Antimicrobial Stewardship - See Acute & Emergency Services No .12410/12410(P)

Cleaning and Disinfection of Non-critical Medical Equipment or Devices (See Risk

Management Section, Policy and Procedure 7207/7207(P)

Day Surgery Post Discharge Phone Follow-up/Patient Satisfaction Survey .......11604

Day Surgery Post discharge Phone Follow-up/Patient Satisfaction

Survey Procedure .............................................................................................11604(P)

Post Discharge Phone Follow-up .............................................................Appendix A

Pain Algorithm .........................................................................................Appendix B

Bladder, Bowel, Diet Algorithm ..............................................................Appendix C

Operative Site/Dressing Algorithm..........................................................Appendix D

Active Daily Living Algorithm ................................................................Appendix E

Day Surgery Units................................................................................................11601

Day Surgery Units Procedure ..............................................................................11601(P)

Admission Assessment and History – Day/Night Care: Surgery ...........Appendix A

PreOp/PostOp Teaching Record ..............................................................Appendix B

Needs Assessment and Record of Care Post-Anaesthetic .......................Appendix C

Mechanical Compression Stocking......................................................................11603

Mechanical Compression Stocking Therapy Procedure ......................................11603

Instruction For Use Of SCD ....................................................................Appendix A

Medication Reconciliation for Post-Operative Patients .......................................11602

Medication Reconciliation for Post-Operative Patients Procedure .....................11602(P)

Surgical Discharge Instructions ...........................................................................11600

Surgical Discharge Instructions Procedure ..........................................................11600(P)

OR (11700 – 11799)

Antimicrobial Stewardship - See Acute & Emergency Services No .12410/12410(P)

Asepsis – Principles for Surgical Procedures ......................................................11707

Asepsis – Principles for Surgical Procedures ......................................................11707(P)

Dress Code in Surgical Suites ..............................................................................11704

Dress Code in Surgical Suites Procedure.............................................................11704(P)

Gowning & Gloving ............................................................................................11706

Gowning & Gloving Procedure ...........................................................................11706(P)

Humidity Management in OR Theatres and Rooms for Medical Device

Reprocessing Sterile Storage ...........................................................................11711

Humidity Management in OR Theatres and Rooms for Medical Device

Reprocessing Sterile Storage Procedure ..........................................................11711(P)

High Relative Humidity in Sterile Storage Areas ....................................Appendix A

Infection Prevention & Control Processes – Surgical Services ...........................11703

Infection Prevention & Control Processes – Surgical Services Procedure ..........11703(P)

Mission Statement ................................................................................................11700

Standards, Guidelines, Position Statements & Competencies for

Regional Operating Units ................................................................................11701

Standards, Guidelines, Position Statements & Competencies for

Regional Operating Units Procedure ...............................................................11701(P)

Surgical Safety Checklist .....................................................................................11702

Surgical Safety Checklist Guide ..............................................................Appendix A

Surgical Safety Checklist Procedure ....................................................................11702(P)

Surgical Site Infection Bundle .............................................................................11708

Daily Audit Tool .....................................................................................Appendix A

Monthly Audit Tool .................................................................................Appendix B

Surgical Site Infection Bundle Procedure ............................................................11708(P)

Surgical Site Verification .....................................................................................11709

Surgical Site Verification Procedure ...................................................................11709(P)

Traffic Control .....................................................................................................11705

Traffic Control Procedure ....................................................................................11705(P)

Transfer of Patient Care from the OR to Recovery Room...................................11712

Transfer of Patient Care from the OR to Recovery Room Procedure .................11712(P)

Vendors in OR ....................................................................................................11713

Vendors in OR Procedure ....................................................................................11713(P)

Visitors List – Vendors in OR Form ........................................................11713(F)

Intensive Care (11800 – 11899)

Medical Device Reprocessing (MDR) (11900 – 11999)

Antimicrobial Stewardship - See Acute & Emergency Services No .12410/12410(P)

Cleaning of MDR & Sterile Storage Areas..........................................................11909

Cleaning Frequency of MDR & Sterile Storage Areas ..........................Appendix A

Cleaning of MDR & Sterile Storage Areas Procedure ........................................11909(P)

Disposable/Single Use Items ...............................................................................11916

Disposables/Single Use Items Procedure.............................................................11916(P)

Education Requirements & Continuing Education ..............................................11902

Education Requirements & Continuing Education Procedure .............................11902(P)

Endoscopy Orientation, Certification for Reprocessing and Transport ...............11900

Event Related Sterility .........................................................................................11905

Event Related Sterility Procedure ........................................................................11905(P)

Flash Sterilization ................................................................................................11912

Flash Sterilization Procedure ...............................................................................11912(P)

Instruments Sets in Rigid Containers (Sterilization Validation of) .....................11917

Instruments Sets in Rigid Containers Procedure (Sterilization Validation of) ....11917(P)

Manufacturer’s Recommendations ......................................................................11904

Manufacturer’s Recommendations Procedure .....................................................11904(P)

MDR Dress Code – Decontamination .................................................................11915

MDR Philosophy & Objective .............................................................................11914

MDR Philosophy & Objective Procedure............................................................11914(P)

New Equipment, Purchasing of ...........................................................................11913

New Equipment Procedure, Purchasing of ..........................................................11913(P)

Physical Space .....................................................................................................11903

Physical Space Procedure ....................................................................................11903(P)

Quality Assurance Test for Steris Washer/Disinfectors, Monitoring of ..............11911

Quality Assurance Test for Steris Washer/Disinfectors Procedure,

Monitoring of ...................................................................................................11911(P)

Quality Management – Documentation of Endoscopy Reprocessing

Procedures ........................................................................................................11901

Quality Management – Documentation of Endoscopy Reprocessing

Procedures ........................................................................................................11901(P)

Sentinel Event (Critical Incident) ........................................................................11908

Sentinel Event (Critical Incident) Procedure .......................................................11908(P)

Sterilized Autoclaved Goods, Handling of ..........................................................11906

Sterilized Autoclaved Goods, Handling of Procedure .........................................11906(P)

Sterilizer Failure Recall .......................................................................................11907

Sterilizer Failure Recall Procedure ......................................................................11907(P)

Sterrad NX (Biological Monitoring) ....................................................................11910

Sterrad NX (Biological Monitoring) Procedure ..................................................11910(P)

Emergency (12000 – 12199) AED Use by First Responders .............................................................................12102

Allocation of Relief Work ...................................................................................12103

Coordinated Transfers ..........................................................................................12104

Coordinated Transfers Procedure ........................................................................12104(P)

Determining Who Will Attend Patients During Ambulance Transfers ...............12001

Scope of Practice Chart for EMS Personnel ............................................Appendix A

Emergency Surgical Booking ..............................................................................12000

Emergency Surgical Bookings Procedure ...........................................................12000(P)

Establishment of a First Responder Group ..........................................................12105

First Responder Team Establishment Criteria .........................................Appendix A

First Responder Group Procedure ........................................................................12105(P)

Nurse Escort Authorization for First Nations Clients ..........................................12106

Authorization for Special Attendant for Road Ambulance ......................Appendix A

Nurse Escort Authorization for First Nations Clients Procedure.........................12106(P)

Over Capacity Protocol (OCP) and Escalation Plan ............................................12003

Over Capacity Protocol (OCP) and Escalation Plan Procedure...........................12003(P)

OCP ED Manager/Charge Nurse Check List ...........................................Appendix A

OCP Decision Tool ..................................................................................Appendix B

OCP – Activation .....................................................................................Appendix C

OCP – Escalation .....................................................................................Appendix D

OCP Procedure for Transferring Site to Site When Over Census ...........Appendix E1

OCP Neighboring Site Bed Availability and On Call Physicians ...........Appendix E2

OCP – De-activation ................................................................................Appendix F

OCP Process Information and Evaluation ...............................................Appendix G

Patient Care Reports ............................................................................................12107

Procedural Sedation .............................................................................................12002

Levels of Sedation....................................................................................Appendix A

Modified Aldrete Scoring System ...........................................................Appendix B

Medication Considerations in Pregnancy and Lactation .........................Appendix C

Emergency Procedural Sedation – Physician Record ..............................Appendix D

Emergency Procedural Sedation – Documentation Record .....................Appendix E

IM Ketamine Protocol..............................................................................Appendix F

Procedural Sedation Procedure ............................................................................12002(P)

Discharge Instructions Post-Procedural Sedation ....................................Appendix G

Procedural Sedation Safety Checklist ......................................................Appendix H

Ride-Alongs .........................................................................................................12108

Shift Trades ..........................................................................................................12109

Standardized Kilometre Charges for Inter-facility Transfers ..............................12110

Travel Through Unfamiliar Areas .......................................................................12113

Travel Through Unfamiliar Areas Procedure ......................................................12113(P)

EMS Stations in Alberta ..........................................................................Appendix A

Saskatchewan Health Regions and Facility Designations .......................Appendix B

2009 Designation of Facilities Operated by RHAs..................................Appendix C

Alberta Health Services Emergency Departments ...................................Appendix D

Treatment of Minors ............................................................................................12111

Vacation ...............................................................................................................12112

Vehicle Operations...............................................................................................12101

Ambulatory Care (12200 – 12399)

Pharmacy (12400 – 12599)

Antimicrobial Stewardship ..................................................................................12410

Antimicrobial Stewardship Procedure .................................................................12410(P)

Antimicrobial Stewardship Audit Tool ....................................................Appendix A

Epinephrine For Inhalation ..................................................................................12403

High-Alert Medications .......................................................................................12406

PNRHA Safety Audit: Accessibility & Handling of Concentrated .........Appendix A

Drugs – Urban & Rural Version

High-Alert Medications Procedure ......................................................................12406(P)

Imprecise and Range Doses .................................................................................12401

Meperidine (Demerol) – Restricted Use ..............................................................12409

Meperidine (Demerol) – Restricted Use Procedure .............................................12409(P)

Methotrexate Preparation & Administration .......................................................12407

Methotrexate Preparation & Administration Procedure ......................................12407(P)

Potassium Chloride For Infusion .........................................................................12402

Potassium Chloride For Infusion Procedure ............................................12402(P)

Potassium Chloride ..................................................................................Appendix A

Restricted Drugs...................................................................................................12405

Current Restricted Drugs in PNRHA .......................................................Appendix A

Restricted Drugs Procedure .................................................................................12405(P)

Safe Drug Storage ................................................................................................12404

Safe Drug Storage Procedure ...............................................................................12404(P)

Diagnostic Services (12600 – 12799) Critical Value Policy ............................................................................................12605

D-Dimer for Diagnosis of VTE ...........................................................................12609

Electrolytes, Total CO2 and Anion Gap ...............................................................12607

Estimated Glomerular Filtration Rate (eGFR) Guideline ....................................12608

Fetal Fibronectin ..................................................................................................12600

Fetal Fibronectin Procedure .................................................................................12600(P)

Fetal Fibronectin Testing Requisition ......................................................Appendix A

Guideline for the Ordering of Erythrocyte Sedimentation Rate (ESR) ...............12606

Informed Consent and Refusal of Consent for Blood Components

and Plasma Protein Products ............................................................................12610

MRI Booking Protocol .........................................................................................12601

Rapid HIV Point of Care Testing.........................................................................12603

Rapid HIV Point of Care Testing Procedure .......................................................12603(P1)

Factors Associated with High Risk for HIV ............................................Appendix A

Instructions for SDCL Chemistry & Immunoserology Requisition. .......Appendix B

SDCL Chemistry & Immunoserology Requisition ..................................Appendix C

RHA Coordinator Responsibilities ..........................................................Appendix D

Rapid HIV Pre-Test and Post-Test Counselling Procedure .................................12603(P2)

HIV Point of Care Testing Brochure .......................................................Appendix A

Troponin T Protocol .............................................................................................12604

Troponin T POC & High Sensitivity Troponin T Algorithm ..................Appendix A

WHO Definition of Myocardial Infarction ..............................................Appendix C

Umbilical Cord Blood Gas Collection/Analysis ..................................................12602

Respiratory (12800 – 12999) Mechanical Ventilation In A Non-ICU Setting ...................................................12800

Ventilator Monitoring Checklist ..............................................................Appendix A

SECTION 13000 – 13999: RURAL HEALTH FACILITIES

Emergency Practice Guidelines: Development Of .............................................13002

Emergency Practice Guidelines Procedure: Development Of ............................13002(P)

Emergency Practice Guidelines For Acute Blood Loss ...........................Appendix A

Emergency Practice Guidelines For Acute Bronchospasm .....................Appendix B

Emergency Practice Guidelines For Acute Abdominal Pain ...................Appendix C

Emergency Practice Guidelines For Acute Allergic Reaction .................Appendix D

Emergency Practice Guidelines For Unconscious Patient .......................Appendix E

Emergency Practice Guidelines For Adult Pain ......................................Appendix F

Emergency Practice Guidelines For Severe Trauma ...............................Appendix G

Emergency Practice Guidelines For Seizures ..........................................Appendix H

Emergency Practice Guidelines For Severe Burns ..................................Appendix I

Emergency Practice Guidelines For The Overdose Patient .....................Appendix J

Emergency Practice Guidelines For Acute Congestive Heart Failure/

Pulmonary Edema ................................................................................Appendix K

Emergency Practice Guidelines For Acute Stroke ...................................Appendix L

Patient Admissions to Rural Health Care Facilities .............................................13001

Patient Admissions to Rural Health Care Facilities Procedure ...........................13001(P)

Rural ER Service Interruption – No Physician ....................................................13003

Public Notice ............................................................................................Appendix A

Rural ER Service Interruption – No Physician Procedure ...................................13003(P)

Triage & Acuity Scale .........................................................................................13004

Triage & Acuity Scale Procedure ........................................................................13004(P)

Patient Letter – Maidstone .......................................................................Appendix A

Patient Letter – Riverside Health Complex .............................................Appendix B

SECTION 14000 – 14999: MEDICAL SERVICES

Disruptive Physician Behavior ............................................................................14001

Disruptive Physician Behavior Procedure ...........................................................14001(P)

Disruptive Physician Behavior Implementation Guide ...........................Appendix A

Pre-printed Orders – Development Medication Orders .......................................14002

Pre-printed Orders – Development Medication Orders Procedure ......................14002(P)

Accountability Framework ......................................................................Appendix A

Approved List of PNHR Pre-printed Orders ...........................................Appendix B

Request to Develop Pre-printed Orders ...................................................Appendix C

Physician’s Preprinted Orders..................................................................Appendix D

SECTION 15000 – 15999: CONTINUING CARE

Long Term Care (15000-15299)

Bowel Care – Administration of Fleet Enema .....................................................15000

Bowel Care – Administration of Fleet Enema Procedure ....................................15000(P)

Cleaning and Disinfection of Non-critical Medical Equipment or Devices (See Risk

Management Section, Policy and Procedure 7207/7207(P)

Coroner Case ........................................................................................................15011

Coroner Case Procedure ......................................................................................15011(P)

Inter-facility Transfer of the Resident Chart ........................................................15005

Inter-facility Transfer of the Resident Chart Procedure ......................................15005(P)

Transferred Resident Demographic Form ...............................................Appendix A

Managed Risk Agreement....................................................................................15013

Managed Risk Agreement Procedure ..................................................................15013(P)

Managed Risk Negotiated Agreement .....................................................Appendix A

Monitoring Oxygen Tank Levels .........................................................................15003

Monitoring Oxygen Tank Levels Procedure........................................................15003(P)

Night Rounds of Residents ..................................................................................15012

Night Rounds of Residents Procedure .................................................................15012(P)

Notification Medical Practitioners .......................................................................15004

Notification Medical Practitioners Procedure ......................................................15004(P)

Nurse In Charge – Roles & Responsibilities .......................................................15007

Nurse In Charge – Roles & Responsibilities Procedure ......................................15007(P)

Oxygen Humidification .......................................................................................15010

Client Care Equipment Cleaning Guidelines ...........................................Appendix A

Oxygen Humidification Procedure ......................................................................15010(P)

Prevention of Resident Fall From Toilet .............................................................15009

Prevention of Resident Fall From Toilet Procedure ............................................15009(P)

Resident Care Conference ....................................................................................15008

Resident Care Conference Procedure ......................................................15008(P)

Formal Letter ...........................................................................................Appendix A

Supportive/Continuing Care Satisfaction Survey ....................................Appendix B

Resident Care Conference – Resident Care Assessment .........................Appendix C

Safe Lifting Protocol ............................................................................................15002

Safe Lifting Protocol Procedure ...........................................................................15002(P)

Safety Measures for Lifting Devices and Slings..................................................15001

Safety Measures for Lifting Devices and Slings Procedure ................................15001(P)

Visitors .................................................................................................................15006

Single Entry Point (15300 – 15499) Single Entry Point – Appeal Process ...................................................................15310

Single Entry Point – Assessment Process ............................................................15302

Single Entry Point – Client Refusal of Vacant Long-Term Bed .........................15311

Single Entry Point – Guiding Principles ..............................................................15301

Single Entry Point – Long Term Care Charges ...................................................15313

Single Entry Point – Placement Committee.........................................................15300

Single Entry Point – Placement Process ..............................................................15303

Single Entry Point – Placement Process – Filling Vacant LTC Beds..................15304

Single Entry Point – Placement Process – Placement Outside

Desired Community/Facility ............................................................................15306

Single Entry Point – Placement Process – Transfer List .....................................15309

Single Entry Point – Placement Process – Transfer of a

Resident to Another LTC Facility....................................................................15307

Single Entry Point – Placement Process – Waiting List ......................................15308

Single Entry Point – Respite Care Charges .........................................................15312

Single Entry Point – Tracking of Vacant Beds and Waiting for Placement ........15305

Vacant LTC Beds Filled Within Twenty Four Hours ..........................................15314

Vacant LTC Beds Filled Within Twenty Four Hours Procedure ........................15314(P)

Home Care (15500 – 15699)

Assessment & Approval Process .........................................................................15564

Assessment & Approval Process Procedure ........................................................15564(P)

Assessment – Client Rights .................................................................................15563

Assessment – Client Rights Procedure ................................................................15563(P)

Home Care Consent Form .......................................................................Appendix A

Assessment Process .............................................................................................15562

Assessment Process Procedure ............................................................................15562(P)

Care Plan ..............................................................................................................15581

Care Plan Procedure .............................................................................................15581(P)

Care Plan – Implementation Of Home Services ..................................................15583

Cleaning and Disinfection of Non-critical Medical Equipment or Devices (See Risk

Management Section, Policy and Procedure 7207/7207(P)

Client Records ......................................................................................................15591

Client Records Procedure ....................................................................................15591(P)

Client Right To Appeal ........................................................................................15565

Client Right To Appeal Procedure .......................................................................15565(P)

Consent ................................................................................................................15541

Consent Procedure ...................................................................................15541(P)

Home Care Consent Form .......................................................................Appendix A

Home Care Intravenous Therapy Program Client Consent .....................Appendix B

Home Care Consent For Medication Management Assistance ...............Appendix C

Death Protocol – Pronouncement ........................................................................15647

Dress Code ...........................................................................................................15651

Dress Code Procedure ..........................................................................................15651(P)

General Discharge Criteria ..................................................................................15585

General Discharge Criteria Procedure .................................................................15585(P)

Medication Reconciliation in Home Care – Admission ......................................15579

Home Care Medication Reconciliation – Physician Order Form ............Appendix A

Physician RN(NP) Orders – Home Care .................................................Appendix B

Medication Reconciliation in Home Care – Admission Procedure .....................15579(P)

Medication Reconciliation in Home Care – Referral or Transfer and Discharge 15580

Medication Reconciliation in Home Care – Referral or Transfer and

Discharge Procedure ........................................................................................15580(P)

Methotrexate Preparation & Administration .......................................................15649

Methotrexate Preparation & Administration Procedure ......................................15649(P)

Oxygen Humidification .......................................................................................15650

Oxygen Humidification Procedure ......................................................................15650(P)

Reassessment/Revision Of Care Plans.................................................................15584

Reassessment/Revision of Care Plan Procedure ..................................................15584(P)

Service Allocations ..............................................................................................15614

Home Care Service Allocation Guidelines ..............................................Appendix A

Service Allocations Procedure .............................................................................15614(P)

Steam Sterilization of Foot Care Instruments ......................................................15646

Steam Sterilization of Foot Care Instruments Procedure .....................................15646(P)

Medical Device Tracking Form ...............................................................Appendix A

TLR in Home Care to Include Adult Day Program and Enriched Housing ........15582

TLR in Home Care to Include Adult Day Program and Enriched Housing

Procedure .........................................................................................................15582(P)

General Inspection – Lifts and Slings ......................................................Appendix A

Venipuncture ........................................................................................................15648

Venipuncture Procedure.......................................................................................15648(P)

Palliative Care (15700-15999)

SECTION 16000 – 17999: COMMUNITY HEALTH

Public Health (16000 – 16300) Anaphylaxis Management ...................................................................................16001

Anaphylaxis Management Procedure ..................................................................16001(P)

Record of Transfer of Medical Function - Immunization ........................Appendix A

Initial Treatment of Immediate Allergic Reactions .................................Appendix B

Epinephrine Dosages According to Weight/Age .....................................Appendix C

Benadryl Oral Treatment .........................................................................Appendix D

Authorization for PHNs to Provide Immunization & Prophylactic Anti-

Malarial Medication .........................................................................................16006

Special Nursing Procedure – Immunization ............................................Appendix A

Record of Transfer of Medical Function – Immunization .......................Appendix B

Record of Transfer of Medical Function – Prophylactic .........................Appendix C

Authorization for PHNs to Provide Immunization & Prophylactic Anti-

Malarial Medication Procedure........................................................................16006(P)

Calibration and Maintenance of Weigh Scales ....................................................16009

Calibration and Maintenance of Weigh Scales Procedure ...................................16009(P)

Scale Verification Report .........................................................................Appendix A

Inventory of Scales ..................................................................................Appendix B

Cleaning and Sanitizing Toys and Contact Surfaces ...........................................16016

Cleaning and Sanitizing Toys and Contact Surfaces Procedure ..........................16016(P)

Condom Distribution Sexual Health Program .....................................................16018

Condom Distribution Sexual Health Program Procedure ....................................16018(P)

Dress Code – Public Health Nursing ...................................................................16019

Dress Code Procedure – Public Health Nursing ..................................................16019(P)

Follow-up Of Children Who Are Overdue For Immunization ............................16013

Follow-up Of Children Who Are Overdue For Immunization Procedure ...........16013(P)

Reminder Notice ......................................................................................Appendix A

Immunization Provided in the School Setting .....................................................16014

Immunization Provided in the School Setting Procedure ....................................16014(P)

Request for Immunization Records Form ................................................Form 1

Consent For Release of Information Form ..............................................Form 2

Obtaining Informed Consent by Telephone .............................................Appendix A

Immunizations Protect Your Child ..........................................................Appendix B

Incomplete Immunization Letter..............................................................Appendix C

Immunization Complete Letter ................................................................Appendix D

In-Depth Assessment ...........................................................................................16005

KidsFirst In-Depth Family Assessment Tool ..........................................Appendix A

Scoring Guide ..........................................................................................Appendix B

International Travel/Adult Clinics .......................................................................16010

International Travel/Adult Clinics Procedure ......................................................16010(P)

Physician Letter .......................................................................................Appendix A

Group Travel Education Record ..............................................................Appendix B

Travel Worksheet .....................................................................................Appendix C

Loan and Care of Breast Pumps ...........................................................................16004

Needle Exchange Program ...................................................................................16003

Needle Exchange Program Procedure .................................................................16003(P)

Harm Reduction Programs .......................................................................Appendix A

Routine Precautions .................................................................................Appendix B

Needle Exchange Protocol .......................................................................Appendix C

Follow-up of a Needle Stick Injury .........................................................Appendix D

Importance of Obtaining Client Information in Needle Exchange ..........Appendix E

Needle Drop Boxes ..................................................................................Appendix F

Sharps Return Initiatives ..........................................................................Appendix G

Post Surgical Follow-up After Dental Surgery With General Anesthesia ...........16017

Post Surgical Follow-up After Dental Surgery With General Anesthesia

Procedure .........................................................................................................16017(P)

Public Health Nursing: Postnatal Services .........................................................16007

Public Health Nursing: Postnatal Services Procedure ........................................16007(P)

Postnatal Services Pamphlet ....................................................................Appendix A

Public Health Nursing Postnatal Program Coverage Areas .....................Appendix B

Postnatal Services In-Hospital Log ..........................................................Appendix C

Client Demographics ...............................................................................Appendix D

Welcome Letter ........................................................................................Appendix E

Postnatal Contact – Mother ......................................................................Appendix F

Postnatal Contact – Child.........................................................................Appendix G

Postnatal Package Contents .....................................................................Appendix H

Referral Form ...........................................................................................Appendix I

Growth Chart – Girls ...............................................................................Appendix J

Growth Chart – Boys ...............................................................................Appendix K

Obstetrical Discharge Care Plan For Mother and Baby ...........................Appendix L

EPDS Screening & Care Guide ...............................................................Appendix M

Assessment of Latch Check-off Sheet .....................................................Appendix N

Rubella Immunization for Adult Women ............................................................16002

Rubella Immunization for Adult Women Procedure ...........................................16002(P)

Rubella Letter...........................................................................................Appendix A

MMR Vaccination for Postnatal Women in PNHR .................................Appendix B

Sexual Health Services at the Meadow Lake Associate Clinic ...........................16011

Sexual Health Services at the Meadow Lake Associate Clinic Procedure ..........16011(P)

STI Infection Assessment, Diagnosis and Treatment ..............................Appendix A

Treatment Protocols for Treatment of Contacts .......................................Appendix B

Standing Orders for Medication and Immunization ................................Appendix C

Standing Orders for Referrals to the NWHF Laboratory .........................Appendix D

Sask. Ministry of Health Virology ..........................................................Appendix E

HIV Pretest Counseling Record ...............................................................Appendix F

Criminal Code Info ..................................................................................Appendix G

Sexual Health Services Orientation Document........................................Appendix H

Staff Education – Breastfeeding (Mandatory) See Acute & Emergency Services #11415

Staff Education – Breastfeeding (Mandatory) Proc. See Acute Emer. Services # 11415(P)

Student Nurses Role in the Provision of Immunization.......................................16012

SRNA Letter to Manager of Public Health Nurses ..................................Appendix A

Student Nurses Role in the Provision of Immunization Procedure .....................16012(P)

Tobacco Reduction Policy/Procedure – Tobacco & Smoke-Free Property (See Community

Health Section, Policy 17502)

Varicella Immunization Program .........................................................................16008

Varicella Immunization Program Procedure .......................................................16008(P)

Varicella Letter ........................................................................................Appendix A

Infection Control (16301 – 16600)

Cleaning and Disinfection of Non-critical Medical Equipment or Devices (See Risk

Management Section, Policy and Procedure 7207/7207(P)

General (16601 – 17000)

Environmental Services (17001 – 17500)

Health Promotion & Disease Prevention (17501 – 17999) Healthy Food Policy ............................................................................................17501

Canada’s Food Guide Suggests ...............................................................Appendix A

SAHO Resolution ....................................................................................Appendix B

Portion Sizes ............................................................................................Appendix C

Applying the Healthy Food Policy ..........................................................Appendix D

Sample Menus ..........................................................................................Appendix E

Healthy Vending, Snack Boxes, Gift Shops & Canteen Ideas ................Appendix F

Healthy Incentive Ideas............................................................................Appendix G

Healthy Fundraising .................................................................................Appendix H

Tobacco Reduction Policy – Tobacco & Smoke-Free Property ..........................17502

Ceremonial Use of Tobacco Reference ...................................................Appendix A

Smoking Reference in OH&S Regulations ..............................................Appendix B

Tobacco Reduction Procedure – Tobacco & Smoke-Free Property ....................17502(P)

Tobacco Cessation Intervention Flow Sheet............................................Appendix C

Nicotine Replacement Therapy Orders ....................................................Appendix D

PNRHA Expense Claim ...........................................................................Appendix E

SECTION 18000 – 18999: PRIMARY HEALTH CARE

Med Access Authorization to Access ..................................................................18003

Med Access Authorization to Access Procedure .................................................18003(P)

Med Access Account Request Form ........................................................Appendix A

Med Access Account Request Administrative Form ...............................Appendix B

Med Access Client Registration...........................................................................18004

Med Access Client Registration Procedure .........................................................18004(P)

Med Access Demographics Clean-up and Merging Client Charts ......................18005

Med Access Demographics Clean-up and Merging Client Charts Procedure .....18005(P)

Med Access Orientation & Training ....................................................................18002

Med Access Orientation & Training Procedure...................................................18002(P)

Med Access Use ...................................................................................................18001

RN/NP Fee Collection .........................................................................................18000

SECTION 19000 – 19999: THERAPIES

Therapies General (19000 – 19100)

Physical Therapy (19101 – 19299)

Occupational Therapy (19300 – 19599)

SLP (19600 – 19799)

Early Childhood Psychology (19800 – 19999)

SECTION 20000 – 20999: INTERSECTORAL PROGRAMMING

SECTION 21000 – 21999: MENTAL HEALTH & ADDICTIONS

Mental Health (21000 – 21499)

Addictions (21500 – 21999)

Admission Policy Detox Unit ..............................................................................21500

Tobacco Reduction Policy/Procedure – Tobacco & Smoke-Free Property (See Community

Health Section, Policy 17502)

SECTION 22000 – 22999: SHNB

SECTION 23000 – 23999: SUPPORT SERVICES

Dietary (23000 -23250) Catering Services .................................................................................................23033

Catering Services Requisition ..................................................................23033(F)

Dress Code ...........................................................................................................23050

Dress Code Procedure ..........................................................................................23050(P)

Dry Food Storage .................................................................................................23010

Food Donations ....................................................................................................23006

Food Recalls.........................................................................................................23052

Food Recalls Procedure .......................................................................................23052(P)

Food Recall Check ...................................................................................Appendix A

Food Storage ........................................................................................................23007

Frozen Food Storage ............................................................................................23009

Healthy Food Policy (See Community Health Section, Policy 17501)

Personal Hygiene .................................................................................................23051

Preparation and Service of Texture Modified Foods ...........................................23026

Preparation and Service of Texture Modified Foods Procedure ..........................23026(P)

Mesh Screen and Spoonability Testing Chart for Pureed and

Minced Food ........................................................................................Appendix A

Purchases From Food Services ............................................................................23002

Refrigerated Food Storage ...................................................................................23008

Refrigerator/Freezer Temperature Checks ...........................................................23011

Maintenance (23251 – 23500)

Infection Prevention & Control for Patient Care and Related Facilities During

Construction, Renovation and Maintenance ....................................................23253

PNRHA Construction Guidance for Projects (2010) ...............................Appendix A

Post Construction Checklist .....................................................................Appendix B

Infection Prevention & Control for Patient Care and Related Facilities During

Construction, Renovation and Maintenance Procedure ...................................23253(P)

Preventative Maintenance ....................................................................................23252

Preventative Maintenance Procedure ...................................................................23252(P)

Service Contracts/Megamation ............................................................................23254

Service Contracts/Megamation Procedure ...........................................................23254(P)

Snow & Ice Control .............................................................................................23251

Snow & Ice Control Procedure ............................................................................23251(P)

Storage and Handling of Liquid Chemical ..........................................................23256

Storage and Handling of Liquid Anesthetic .........................................................23256(P1)

Supplemental Heat ...............................................................................................23255

Supplemental Heat Procedure ..............................................................................23255(P)

Supplemental Heat Inspection Checklist .................................................Appendix A

Housekeeping (23501 – 23800)

Cleaning and Disinfection of Non-critical Medical Equipment or Devices (See Risk

Management Section, Policy and Procedure 7207/7207(P)

Laundry (23801 – 23999)

SECTION 24000 – 24999: TELEHEALTH

Admin (24000 – 24199)

Equipment (24200 – 24399)

Cleaning and Disinfection of Non-critical Medical Equipment or Devices (See Risk

Management Section, Policy and Procedure 7207/7207(P)

Clinical (24400 – 24599)

Education/Meeting (24600 – 24799)

Other (24800 – 24999)

SECTION 25000 – 25999: INFORMATION TECHNOLOGY

IT Security (25000 – 25299) Cell Phone and Hand-Held Devices ....................................................................25004

Information Security – Termination of Employment ..........................................25005

Information Security – Termination of Employment Procedure .........................25005(P)

Information Security – Texting Policy ................................................................25006

IT Acceptable Usage ...........................................................................................25003

Internet Use ..............................................................................................Appendix A

E-mail .......................................................................................................Appendix B

Online Discussion Groups, Games, Voice Mail, Mobile Computing Devices

(i.e. PDA’s, Data Storage, Cellular Phone & Photocopiers ...............Appendix C

IT Password Policy ..............................................................................................25002

IT Password Procedure ........................................................................................25002(P)

IT Remote Access ................................................................................................25001

IT Operations (25300 – 25499)

Change Management ...........................................................................................25300