If your Center has contracted with us to provide you with a set of program policies, they will be customized for the type of specialties, accreditation, and state regulations, among many other criteria.

To search use: "CTRL" + "F" key.


FC Section 

Intermediary Carrier Directory   

Obtaining a Durable Medical Equipment Number               

F Section         


Reference Books for Billing ASC Services

Enrollment as a Provider

Fee Estimates

Bills or Statements

Patient Charges

Making Financial Arrangements

Payment Plans

Verification of Eligibility

Initiial Billing

Billing Patients for Services Rendered

Medicare Payment Coverage

Advance Beneficiary Notice (ABN)

Reimburing Terminated Surgery

Claim Forms

Collections Procedures

Collecting Overdue Accounts

Account Adjustments

Bookkeeping Documents

Managing Insurance Claims

Claims in Process

Following Up on Overdue Claims

Filing Worker's Compensation Claims

Filing Medicare Claims



Petty Cash

Monthly Statements

Business Records

End of day Records

Purged Accounts

Establishing and Monitoring Budget

Maintaining Medicare Compliance

Recording and Posting Payments

Proper Use of the Credit Card Machine

Billing for a Prosthetic and Tissue Implants

Patient Billing When There is No Secondary

Secondary Billing

Handling of Deceased Patient Account Balance


Fee Agreements

Creating Billing Record

Waiver of Payment

Managed Care Company Payment Proposal

Sending an Account to Collections

Accounts Receivable Area Quality Improvement Review

Review Request for Medicare Denied Claims

Hearing Request for a Denied Claim

HIPAA Compliance in the Business Office

FS Section         

Fee Schedule

FG Section         

Monthly General Ledger

QC Section         

Quality Improvement in Financial Management

FR Section         







AN Section 

Anesthesia Services   

Anesthesia Personnel Roles               

Use of Anesthesia Technicians          

Anesthesia Education and Training   

Anesthesia Education and Training   

Anesthesia Practice Standards and Guidelines   

ASA Patient Classifications and Eligibility   

Weight Policy

Pre-Operative Testing Guidelines   

Approved Anesthetic Agents

Standards For Mixing and Preparing Anesthetic Agents      

Stages of Anesthesia (GENERAL ANES ONLY) 

Identifying Sleep Apnea

Pre-Operative Screening of the Pediatric Patient

Recommended Practices in Pediatric Anesthesia

ANP Section

Anesthesia Evaluation and Assessment  

Conditions That May Affect The Patient Undergoing a Procedure  

Drugs Interfering With Coagulation  

Monitoring Patients   

Regional Pain Blocks     

Monitored Anesthesia Care   

IV Sedation   


Anesthesia Record           

Anesthesia Post-Op Procedures

Sodium Pentothal Extravasation/ Intra-arterial Injection      

Laryngospasm (GENERAL ANES ONLY)           

Malignant Hyperthermia (GENERAL ANES ONLY)       


Site Verification Prior to Regional Block Anesthesia

Use of Reversal Agents

Guidelines for Managing a Difficult Airway

Post-Operative Nausea and Vomiting

Clinical Privileges: Pediatric Anesthesia

AN-EQ Section

Stocking Anesthesia Agents and Drugs (ANESTHESIA MACHINES)   

Stocking and Cleaning Anesthesia Cart (ANESTHESIA MACHINES)   

Cleaning of Anesthesia Equipment  (ANESTHESIA MACHINES)         

Pediatric Laryngeal Mask (PEDIATRICS ONLY) 

Controlling Anesthesia Drugs

ANG Section 

Safe Delivery of Surgical and Anesthesia Services   

Anesthesia Safety Practices   

Safety Checking Anesthesia Equipment       

Patient Regulations for Anesthesia Safety    

Maintenance Inspection-Anesthesia Machines  (GENERAL ONLY)        

Changing Soda-Lime Canisters  (GENERAL ONLY)       

Scavenger System  (GENERAL ONLY)    

Vaporizer Exchange  (GENERAL ONLY) 

Anesthesia Safety for Laryngotracheal Surgery (ENT Only)      

   Medication Practices in Anesthesia Services
QI Section

  QA/PI in Anesthesia


FF Section
  Emergency Management Planning Criteria (CEMP) 
FO Section (FORMS) 

Disaster Phone Numbers          

Disaster Phone Tree

System Failure and Staff Response Plan           

Emergency Response Team Roster       

Emergency Equipment

Hazard Mitigation Assessment         

Statement of Conditions           

  Hazard Analysis/Potential Disasters
  Bomb Data & Bomb Threat Call Checklist
FM Section 

Disaster Plan Approval (Florida)


Code Alerts      


Hierarchy of Authority   

Emergency Preparedness Plan 

Life Safety Management and Monitoring Plan    

Requirements for Notification Related to Life Safety System Failure       

Interim Life Safety Measures (ILSM)      

Internal Disaster Plan    

External Disaster Plan  

Sheltering In Place        

Fire Emergency Plan    

Personnel Plan of Action

Assessing Facility Vulnerability 

Emergency Response Team     


The Command Post      

Use of the Disaster Phone Tree 

Signaling the Fire Alarm

Code Yellow    

Emergency Warnings    

Preparing for Water Intrusion/Flooding  

Water Management Disaster Plan          

Preparing for a Sinkhole           

Hurricane Safety Plan   

Volcano Safety Plan     

Tornado Safety Plan     

Earthquake Safety        

Healthcare Provider Mass Prophylaxis (only if Community Wide Disaster Planning)

Influenza Pandemic Disaster Plan          

Evacuation Plan           

Internal Evacuation       

Total Facility Evacuation           

Motor Vehicle Accidents           

General Information – Bombs    

Bomb Threat Procedure

Statement of Conditions           

Credentialing Physicians in the Event of Disaster (ACCREDITATION)      

Emergency Vendor Services (Accreditation)      

Fire in the MRI Room (ACCREDITATION)           

Fire in the OR   

Fire Prevention in the Oxygen Enriched Environment      

Fire Watch Procedure   

  Safe Use of the Fire Blanket

Performing a Fire Risk Assessment  

FD Section

Emergency Response Orientation

Fire Prevention and Safety Program

Use of ABC Fire Extinguishers  

Classification of Flammable and Combustible Liquids           

Emergency Response Drills  

DM Section

Essential System Utility Management Plan (ACCREDITATION)            

Environmental Control   

Emergency Equipment and Power Failure    

Emergency Power Supply System Tests (Generator)          

Stored Emergency Power Supply System Tests (Battery)    

Response to Line Isolation Monitor Alarm

Testing the Line Isolation Monitor 

Nurse Call System    

Shut-Off Valves (Piped in Gases)          

Annunciation Monitors       

Elevator Fire Service Inspection Guidelines (ELEVATORS) 

BT Section

Bioterrorism Readiness Plan                                                                                       

Chemical Terrorism                                                                                                     

 Hazard Communication Plan
 Blood Borne Pathogen Exposure Control Plan
EC Section

Exposure Control Plan and Policy     

Hazardous Materials Plan      

Toxic Substance Inventory    

Labeling Toxic Substances    

Defining Toxic Substances    

Safety Data Sheets 

Container Labels

Hazard Communications and Training          

Hazardous Waste Spills

Glutaraldehyde Spills          

Mercury Management Plan

Handling Mercury Spills     

Managing Mercury Sources

Hazardous Waste Explosion  

Cross-Reference and Index to Chemical Hazard Categories

Employee Right-To-Know    

OSHA Regulations Definitions         

Hazardous  Waste Management Plan

Community Right-To-Know Program           

Physically Hazardous Waste Management Plan        

General Waste Management Plan      

Radioactive Waste Management Plan        

Formaldehyde Waste Management Plan

BBP Section

Blood Borne Pathogens Plan    

Infection Prevention/Blood Borne Pathogens Training         

Contamination From Body Fluids/Puncture Wounds From Contaminated Sharps 

Occupational Injury Log

HIV Post Exposure Prophylaxis (PEP)  

Drawing Blood for HIV, HBV and HCV Testing 

HBV Titer and Vaccine  

Information on the Hepatitis B Vaccine  

Tagging and Bagging Infectious Waste 

Soiled Linen Handling   

Waste Disposal

Biohazardous Waste Management Plan (Accreditation)  

Biomedical Waste Plan 

Medical Waste

Fluid Waste Management Plan         

OSHA Final Rule of Occupational Exposure to BBP       

Blood Borne Pathogen Standard/Exposure Control Plan

Exposure Protocol       

Standard Transmission Based Precautions    

Engineering and Work Practice Controls (contains info on eyewash stations, etc.)

Protective Equipment   

Decontamination Procedure      

Identifying Patients with Tuberculosis

TB Risk Assessment 

Tuberculin Skin Testing   



C Section 

Policies and Procedures                                                               

ASC Ownership

Scope of Services                                                    

Description of the Center  

Ancillary Services                                                                           

Facility Hours                                                                                  

Opening Routine for the Facility                                                  

Closing Routine for the Facility                                                    

After Hours Emergencies                                                             

Use of Military Time                                                                       

Answering the Phone                                                                    

Personal Telephone Messages                  

Telephone Courtesy                                                                      

Use of the Intercom                                                                       

Service Animals                                                                             

   Personal Use of Company Equipment and Supplies
   Center Mail
   Use of Personal Vehicles for Company Business
ST Section 

Contractual Agreements        


Visitors in the Facility

Chaplains and Priests in the Facility  

Students in the ASC  

Student Registered Nurse Anesthetists         

Observers in the OR/Procedure Room          

Handling VIPs and the Media           

Fraud, Waste and Abuse Training     

CA Section 

Scheduling of Procedures; Preparation and Distribution of the Procedure Schedule        

Physician Privileges     

Tonsillectomy in an Out-Patient Setting          

Cancellation of Scheduled Procedures  

Case Delays    

Monthly Statistics         

GA Section 

Appointment Control    

Electronic Patient Registration      

Admitting Routine         

Admission Policies       

Patient Valuables         

Patient Attire    

The Care Person as a Team Member     

Refusal of Care

Patient Leaving ASC After Being Admitted for Their Procedure   

Care of the Fainting Responsible Adult Companion (RAC)          





Purpose Responsibilities and Function of the Health Information Program     

General Policies of the Health Information Department


Medical Record Information Flow          

Purpose and Preparation of the Medical Record

Ambulatory Surgical Chart Forms

The Medical Record Contents

Filing an Incomplete Medical Record        

Transcription of Medical Record Reports   

Use of Transcription Services   

Operative Report Procedure      

Use of Abbreviations, Acronyms and Symbols  

Lost Medical Records   

Start and End Times for Anesthesia/Surgery

Physician’s Orders (moved here from Nursing, section P)     

Standing Physician’s Orders     



HIPAA Compliance Plan

Confidentiality of Patient Information         

Security in Electronic Health Records

  Mobile Device Security  

Use of Personal Mobile Devices    

Access to the Medical Record  

Patient Access to Protected Health Information (PHI)     

Patient Right to Request Amendment to Protected Health Information (PHI)        

Identity Theft Prevention Program         

Electronic Transmission of Care Records  (formerly Faxing”…)

Answering Telephone Requests 

Answering Correspondence      

Written Requests for Patient Information ­ Attorney, Insurance Company, etc.     

Subpoena Procedure    

Objection to Subpoena 

Advance Directive in the ASC (moved here from Nursing, NA section)  


Consents for Treatment

 Consents and Surgical Decision Making  
 Informed Consent, Medical/Surgical  

Informed Consent, Anesthesia

Informed Refusal          


Release Against Medical Advice

Transfer of Patient Information

Register of Operations


Preservation and Destruction of PHI      

Scanning of Medical Records

Sequestering Medical Records  

Fire Protection of Medical Records       

Reporting Deaths and Reportable Diseases       

Signature Stamp Usage           

Record Retention in Closure      

Handling Soiled / Contaminated Records       

Use of Electronic Signatures


ADDENDUM – Privacy Rules and Definitions




Employment Applications and Reference Checks          

Interviewing, Selecting and Hiring Staff  

Staff Employment        

Employee Disqualification List (MISSOURI)

Personnel Files

Retention of Human Resources Files     

Dress and Grooming Code

Malpractice Insurance   

Professional Credentials           

Professional Decorum  

Tips and Gratuities       

Drug and Alcohol Use  

Drug Testing    


Unscheduled Absences

Competency Assessment and Validation           

Performance Appraisals           

Performance Incentive Review   

Promotion and Transfer


Grievance Procedure    

Quality of Care Notice (formerly entitled “Joint Commission Notice”)

Break Time for Nursing Mothers

Gossip in the Workplace


Volunteer Services    


Employee Health Program        

Health and Personal Hygiene    

Worker's Compensation Insurance         

Consolidated Omnibus Budget Reconciliation Act (COBRA)       

Life Threatening Illnesses          

Surgical Care   

Sick Leave Due to Infectious Disease 

Providing for Sick Leave Pay

Overtime for Licensed Nursing Personnel


Employee Orientation   

Objectives of Orientation          

Professional Activities/Education          

Educational Financial Assistance          

Dues and Subscriptions

Inservice Education      

Surgical Technician Training Program    

Staff Meetings 

Job Descriptions          



Infection Prevention Program and Committee         

Infection Prevention Inservice         

Staff Members and Infection Prevention    

Infection Prevention Orientation      

Infections, Complications, Outbreaks and Epidemics     

Infection Prevention / Complication Survey (Reinstated 3/10)           

Untoward Break in Technique    

Surgical Wound Classification   

Infectious Disease Assessment ­ Patient           

Traffic Control ­ Surgery Suite   

Traffic Control – Anesthesia Workroom 

Traffic Control - Procedure Rooms        

Visitor Control  

Care of Patient with Scabies     

Care of Patient with Pediculosis            

Clostridium Difficile      

   Prion Diseases, New 10/13

Operating Room Care of Patient with Drug Resistant Organisms (relocated from Nursing OR Section)           

Scrub Attire      


Handwashing and Hand Hygiene   


Surgical Hand Scrub           


Surgical Hand Scrub Using Alcohol Based Products      


Surgical Scrub - Drying Hands After                  


Closed Gowning           


Gloving Routine           

     Use of Utility Gloves




Opening Sterile Packages         




Removing Soiled Gloves, Gowns and Masks

Performing an Infection Prevention Risk Assessment

Reception/Registration Protocol: Potentially Infecitous Patient


Sterilization by Steam Heat – Steam Under Pressure      

Biological Testing         

Chemical Indicators   

Sterilization Guidelines  

Sterilization Standards  

Immediate Use Steam Sterilization (formerly Flash Sterilization)

Sterilizer Maintenance

Weekly Maintenance ­ Sterilizer Chamber           

Servicing Autoclaves    

Chemical Disinfection   

Glutaraldehyde High Level Disinfection  

Use of Personal Monitor Badges          

Glutaraldehyde Training

Validation Testing         

Sterilization Packaging Systems        

Handling and Storage of Sterile Wrapped Instruments    

Autoclave Recorders    

Steris System 1 Sterile Processor         

Biological Monitoring - Steris System 1 

Chemical Monitoring of the Steris System 1       

Infection Prevention Procedures for Flexible Sigmoidoscopy

Infection Prevention Practices in Anesthesia           

Cleaning of Endoscopy Equipment Using KC-10 and Glutaraldehyde      

Cleaning of EVIS Videoscopes 

Manual Cleaning and Processing Scopes          

Decontamination of Video Equipment   

Washer Disinfector       

Reuse of Disposables          

Quality Assessment/Performance Improvement in Sterilization 


Cleaning Equipment and Routine Maintenance   

Processing Soiled Instrumentation        

Care of Microsurgical Instruments         

Care of Ophthalmic Microsurgical Instruments    

Disinfection of Laser Contact Lenses    

Cleaning of Fiberoptic Scopes  

Processing Air, Battery or Electric Powered Instruments 

Cleaning of Sector Probes        

Cleaning and Processing Anesthesia Equipment

Ultrasonic Cleaner        

Ultrasonic Rinser/Dryer


Surgical and Medical Asepsis 


Infection Prevention Glossary        

Contract for Janitorial Services 

Housekeeping Services

Housekeeping Schedules     

Housekeeping Inspection Tours       

Housekeeping Orientation         

Safety in Housekeeping

Preventive Maintenance Cleaning          

Cleaning of Admitting and Business Areas        

Housekeeping and Infection Prevention in the OR/ Procedure Room Suite   

   Cleaning the Procedure Room

Cleaning of the Sterile Processing Area 

Cleaning the Pre-Op and Recovery Areas          

   Cleaning the Medication Preparation Room

Cleaning the Refrigerator          

Cleaning OR Table Beds           

Housekeeping Report of Needed Repairs          


Care of Liquid Soap Dispensers           

Disinfection Guidelines 

Cleaning and Polishing Agents  

Regulated Medical Waste Classifications           

Routine Terminal Cleaning

Cleaning of Ice Dispensers       

Laundry Services          

Linen Pickup, Delivery and Storage       

Trash Pick Up Procedure          

   Management and Use of Corrugated Cardboard Containers




Laboratory Services

Normal Lab Ranges

Stat Test Documentation          

Collection of Blood for Type & Crossmatch       

Administration of Blood or Blood Products       

Administration of Autologous Blood or Blood Products 

Standing Orders for Blood Filter Usage 

Transfusion Reaction    

Blood or Blood Products          

Abnormal Test Results  

Surgical Specimens and Cultures          

Specimens not Requiring Pathology Examination          

Lab Specimens/Containers

Specimen Log  

Performance Improvement in the Lab

Handling Blood Specimens       

Labeling Reagents        

Hematology and Blood Bank Safety Rules        

Dipstick Tests  


Urine Culture Specimens           

Urine Duo Test 

Tandem Icon II HCG Test          

Strep A Test     

Chlamydia Test

Use of Automated Cell Counter 

Chemistry Analyzer for Blood Tests       

Finger Stick Hematocrit

Use of the Centrifuge   

Accu-Chek II Blood Glucose Monitor     

Blood Glucose Testing

Cleaning and Disinfecting of Accu-Chek III Blood Glucose Monitor         

HemaCue Blood Glucose Monitor         

   Use of the STAT-Site Hemacue Analyzer
   Using the INR 2 PT Monitor

Glucometer Elite Glucose Monitor         

TRUE Track Blood Glucose Monitoring System 

Frozen Section 

Performing HP Fast CLOtest     

CLOtest Control Testing

Quality Assessment/Performance Improvement Review of CLOtest Reports           

Pregnancy Testing       

Nicotine Testing      

Waived Testing

QA/PI in Waived Testing

Quality Control in Waived Testing






Laser Safety Committee           


Credentialing Obtaining Laser Privileges




Argon Laser Therapy                


Laser Maintenance        


Safety in Laser Surgery


Assisting with Ophthalmic Laser Surgery           


Orientation to Lasers    


Smoke Evacuation and Odor Control During Laser Surgery        


Management of Tracheal Fires During Laser Use


LASIK Surgery 


Laser Log        


Calibration Procedure   


Key Storage for Laser Units      


Standards of Care        


Standards of Professional Performance


Guidelines for Non-Physician Laser Use


Laser Training Course









Materiels Management Goals and Objectives



Materiels Management Duties



Materiels Management Continuum



The Ordering Process





   Cost Containment

 Establishing the Reorder Point

 Ordering Supplies

 Stockless Purchasing

 Reception and Business Area

 PACU, Discharge and Pre-Op Inventory

 Purchase Orders

 Vendor Sources

 Use of Product Information Cards/Files

 Receipt of Ordered Supplies

 Filing Inventory Information

 Product Substitution

 Returned Goods
Recall Policy

Restocking of Drugs and Supplies

Receiving and Storage






Request for Capital Equipment 



Vendor’s Checklist - Capital Equipment 



Budgeting Capital Equipment    









Master Supply and Drug Inventories      



Master Equipment and Instrument List and Inventory      









Medication Safety Program   



Medication Guidelines

Risk Reduction in High Alert Medications



Drug Inventory



Sample and Investigational Drugs         



Drug Labels and Packaging      



Procurement, Preparation and Storage of Drugs



Drug Procurement (Ordering Drugs)



Ordering Schedule II Drugs       



Drug and Solution Recall          



Drug Product Shortages     



Crediting Excess Drug Inventory           



Expired Drugs, Solutions, and Implants  



Drug Product Problem Reporting Program        



Administration of Medications   



Medication Orders   



Medication Reconciliation     



Multi-Dose Vials      



Adding Adrenalin, Gentamicin and Vancomycin to BSS  



IV Drugs Licensed Nurse Not Allowed to Give    



Expiration Dates on Medications



Adverse Drug Reactions           



IV Additives     



IV Solution Preparation 



Administration of Anti-Aspiration Drugs 



Medication Errors         



Controlled Substance Records and Counts        



Controlled Substance Waste Report      



Maintenance of Records           



Substance Abuse Program       



Medication from Home 



Infusion Pump  



Schedules of Controlled Substances     



Use of the Formulary    



List of Drugs That May Interfere in Coagulation  



Sample Problematic Drugs List 



Pre-Operative Guidelines for Medications          



Administration of RhoGam        



Medication Practices in the OR 



Antineoplastic Agents   



Safe Management of Vaccines 



Use of Diprivan



Herbal Side Effects or Drug Interactions



Anticoagulant Therapy  



Oxygen Therapy           



Hazardous Drugs, Chemicals and Agents Safety Program 



Handling and Disposal of Cytotoxic Medications



“Immediate Use” – Compounding of Sterile Drugs


  Administration of Vancomycin  
     Pharmacy Consultant  
     Safe Injection Practices  





Taking the Blood Pressure        


Use of the Pulse Oximeter        


Taking Temperature, Pulse and Respiration        


Vital Signs Monitor       






Obtaining Pre-Operative Laboratory Specimens 


BOTOX Injection for Blepharospasm     


Instillation of Ear Drops


Instillation of Eye Drops           


Instillation of Nose Drops         


Testing the Pulse Oximeter       


Patient Lead Equipment Checks


Monitoring Diabetes Mellitus     


Vascular Access Lines  


Accessing An implanted Venous Access Device/Port    


LPN Role in IV Therapy 


Intravenous Infusion Rate          


Moving the Patient       


Preparation of 1% Betadine Solution     


Allograft Protocol         


Dropped Grafts


Insertion of Triple Lumen Catheter         


Patient Care in Local Anesthesia           


Patient Undergoing Histamine Phosphate Infusion         


Honan Pressure Application      


Use of the Mercury Bag


Pinky Ball        


Pediatric Feeding Schedule      


Making an Unoccupied Stretcher Bed    


Directions For Use of Hand-Operated Resuscitator Bag 


Cleaning Ambu Resuscitators   


NT Suctioning  


Application of the T.E.D. Stocking        


Applying Cold Treatment          


Applying Elastic Wraps


Care of Casts   


Cast Cutting and Removal        


Use of the Bedpan or Urinal      


Care of the Patient with a Retention Catheter      


Urinary Catheterization of Female Patient           


Urinary Catheterization of Male Patient   


Insertion of a Retention Catheter – Female         


Insertion of a Retention Catheter – Male 


Irrigating a Foley Catheter         


Removal of the Retention Catheter        


Maintaining Peripheral IV Catheter Patency        


Clean Catch Urine Specimen – Adult      


Safe Use of Tourniquets           


Safe Use of Cryosurgical Unit   


Nursing Management of the Pediatric Patient     


Sequential Compression Device


Pledget Application (Ophthalmology)     


Corneal Grafts  


Amniotic Membrane Transplantation (ATM)     


  Log Rolling a Patient
CVP Line Flush 
Preventing Deep Vein Thrombosis
  Care of the Patient with a Tracheostomy  









Setting Up GI Rooms   



Inspecting and Preparing Endoscopes  






Foreign Body Removal ­ Upper 



EGD with Sclerotherapy



Esophageal Dilation with Maloney Dilators        



EGD with Esophageal Dilation using Balloons   



Esophageal Dilation using Savory-Type Dilators



Percutaneous Endoscopic Gastrostomy (PEG)  



Gastrostomy Tube Change       



Cytology Brushings      



Endoscopic Biopsies   



Injection Coagulation ­ Bleeding Sites    



Liver Biopsy     



Flexible Fiberoptic Sigmoidoscopy       






Use of Colonoscopy Injection Needle    



Tap Water Enemas ­ Colon Preps          






Indications for Gastrointestinal Endoscopy

Capsule Endoscopy       








Loaning and Borrowing Equipment


Double Procedures


Care of the Psychiatric Patient  


Unlicensed Assistive Personnel in the Peri-Operative Setting      




CPR Certification and Drills


CPR Code Blue


CPR Report     


Broselow/Hinkle Kit      


Foreign Body Airway Obstruction          


Emergency Tracheostomy                    


Defibrillation Procedure


Defibrillation Procedure – AED 


Testing Defibrillator      


Checking the AED        


Checking the Emergency Cart   


Anaphylactic Shock


Respiratory Distress     


Insulin Reaction






Postmortem Care Time out in the OR        


Time out in the OR

Patient Identifiers    


Surgical Site Identification

Hand-Off Communication

Care of the Morbidly Obese Patient

Death in the Facility  













The Patient In Isolation  


Skin Preparation           


Skin Preparation for Eye Surgery          




Procedures Not Requiring Counts         


Selection and Verification of IOL Prior to Surgery          


Liposuction Surgery (FLORIDA)




Purpose of the Pre-Op Unit       


Pre-Op Staffing and Responsibilities  


Equipment for Patient Station 

Daily Routine Preop Greeting       


Pre-Operative Counseling and Assessment


Patient/Family Education


Falls Prevention Program          


Latex Allergic Patients (IF NOT DOING LATEX ALLERGIC)


Latex Allergy, Nursing Care and Management    


Reducing Latex Allergies          


Admitting the Patient to the Pre-Operative Area      


Documenting Pre-Operative Care          


Xylocaine and Marcaine Skin Testing     


Pre-Operative History & Physical Changes/Additions by Admitting RN    


Nursing Care Plans       


Patient Instructions for Sedation (moved here from Medication Management and renamed




Purpose of the OR/Procedure Suite      


OR/Procedure Suite Staffing


Equipment in the OR/Procedure Rooms


Documenting OR Care


daily routine Surgery Suite     


Supplies in the Surgical Suite    


Turning the Room


Procedure Cards          


Use of the Procedure Room                 


Admitting the Patient to the Operating/Procedure Room 


The Nurse During the Beginning of Anesthesia   


Local Anesthetic           


Nurse Administered IV Conscious Sedation                   


Toxic Reactions to Local Anesthetic Agents                  


Positioning of the Patient         


Use of the Electrosurgical Unit  


Care if the Patient with an IED   


Safe Use of the Cryosurgical Unit         




Purpose of the Unit - Acute Recovery    


Acute Recovery Equipment       


ASA Standards for Post-Anesthesia Care          


Acute Recovery Staffing           


Daily Routine ­ PACU          


Post-Anesthesia Policies          


Recovery Admission Routines  


The PACU Record    


Use of the Aldrete Scoring System       


Standing Orders ­ Laryngospasms        


Emergencies Not Requiring CPR           


Purpose of the Unit - Discharge Recovery         


Discharge Recovery Equipment        


Discharge Recovery Staffing    


Daily Routine - Discharge Recovery      


Discharge Recovery Admission and Care      


Recovery Care - Regional Block Anesthesia       


Recovery Care - Local Anesthesia         


Pain Management         


Pain Assessment         


Post-Op Dietary Intake 


Discharge Criteria & Procedure          


Discharge Planning & Education        


Post-Operative Follow-up    


Electronic Post-Operative Follow-Up by Email


Patient Transfer


Additional Discharge Criteria for Regional Anesthesia    




Pain Center

Patient Admission/Pain Management     


Admission/Discharge Policy     


Adhesion Lysis w/Fluoroscopy 


Adjunctive Support       


Axillary Block   


Bier Block        


Caudal Epidural Steroid Injection (Caudal EPSI) 


Celiac Plexus Block      


Cervical Epidural Steroid Injection (Cervical EPSI)          


Differential Epidural /Spinal Blocks       


Epidural Differential      


Epidural Steroid Injection (ESI)  


Epidural Sympathetic Block      


Facet Nerve Block Injection       


General Nerve Block Orders                  


Ilioinguinal Nerve Block 


Infraorbital Block/Supraorbital Block     


Intrathecal Morphine Injection    


Intercostal Nerve Block 


Lumbar Sympathetic Block (LSB)          


Occipital Nerve Block   


Pain Management Setup w/Continuous Racz Catheter    


Percutaneous Dorsal Column Stimulator


Peripheral IV Local Anesthesia  


Pre-Lumbar Facet Injection        


Radiofrequency Lesion 


Sacro Iliac Joint Injection (SI Joint Injection)       


Selective Epidural Steroid         


Spinal Accessory Nerve Block  


Stellate Ganglion Block            


Sub-Arachnoid Block    


Supraclavicular Nerve Block      


Sympathetic Block       


Synchromed Pump – Surgery or Refill


Trigeminal Nerve Block 


Trigger Points Injections           


Continuous Peripheral Nerve Blocks      



Affirmation of Responsible Committee  

Mission and Goals of the Quality Assessment and Performance Improvement Committee       

Affirmation of Responsible Persons      

QA/PI/RM Organizational Circle       

Cycle of Continuous Improvement         

Closing the Loops        



TQM/ A Shift in Management Paradigms           



Fundamental Total Quality Questions     

QA/PI/RM Committee         

SPDCA Tracking Method for Improvement

Quality Assessment/Performance Improvement Program           

Institutional Review Committee  

TQM Objectives, Discontinued 3/10


Product Evaluation and Selection          

Equipment Purchasing and Selection    

Cost Analysis Studies  

Cost Monitoring           

Financial Accountability

Perception of Care Assessment

Staff and Physician Satisfaction Questionnaire  

Quality Reviews

QA/PI in Medication Safety

Medical Record Review

Anesthesia Review       

Tissue Review  

Abnormal Lab/Test Review        

QA/PI Studies        

QA/PI Report Tools and Forms       

Credentialing and Privileging

Re-Credentialing and Re-Privileging

Private Staff Activities

Adding New Procedures or Services

Proctoring of Physicians          

Utilization Review Plan  

Communication with the Sensory Impaired

Use Of Interpreter Services For Limited English Speaking Persons (LESP)

Monthly Statistics         

Use Of Gel-Filled Breast Implants          

Special Privileges Request       

Standards of Ethical Practice    

Patient Outcomes in Pain Management


Introduction to the Risk Management Program   

Risk Management Plan 

Risk Management Program       

Risk Management Terms           

The Risk Management Process 

Risk Management Goals           

Statement of Commitment        

Annual Report to the State        

Risk Management Orientation    

Risk Management Inservice Education           

Self Assessment/Benchmarking

Patients’ Rights and Responsibilities                     

Incident Reports

Incident Report Logs    

Reporting to State        

Sentinel Events (formerly Sentinel/Adverse Events)          

Adverse Events      

   Reporting Adverse Events   

Preventing Patient Adverse Events   

System for Notifying a Patient of a Serious Adverse Incident     

Adverse Event – Tissue Transplantation        

Reporting Adverse Experiences with Equipment Malfunctions    

National Practitioner Data Bank 

Failure Mode and Effects Analysis        

Patient Grievance and Investigation of Complaints         

Peer Review Program           

Staff Peer Review        

Clinical Practice Guidelines/Medical Necessity   

Reporting Child, Parent or Spouse Abuse          

Vulnerable Adult           

Photographing of Suspected Abuse Victims     

Definition of Abuse      

Occupational Injury Log

Sexual Discrimination, Harassment and Misconduct Toward Employees 

Sexual Misconduct Towards Patients    

Physician Incapacitation           

Incompetent Staff Member       

Impaired Staff Person  

Disruptive Behavior in the Workplace    


Standards for Business Conduct and Corporate Compliance      






Radiology Services


Fluorescein Angiograms           


Radiology and Ultrasound Safety   


X-Ray Request Form    


Interpretation of Mammography Studies


Staffing for Radiographic Studies   


Storage of Films


Radiation Exposure of Pregnant Patients          


Monthly Dosimeter Reports      


Radiation Exposure Badges     


Physicians Procedure Cards – Radiology          


Angiogram, Aortogram and Arteriogram Care     


Pain Management for Radiology per Lumbar Facet Block           


Approved Radiology Procedures          


Education Program for Radiology Staff


Staff Instructions          


X-Ray Examination Orders        


Film Development        


Radiology Reports       


Radiation Protection Rules        


Restricted and Unrestricted Zones         


Exposure of Minors      


Occupational Exposure Limits   


External Sources of Radiation   


Maintenance of Radiology Equipment   


Dispensation of Radiographic Waste    


Corrective Action          


Aspects of Care           


Identifying Indicators    


Evaluation of Care        


Data Collection and Organization          


Common Problems and Possible Causes-Radiology Services    


C-Arm Use


Use of X-Ray Equipment for Diagnostic and Interventional Procedures




Admission to Twenty-Three Hour Stay   

Service Meal Trays       

IV Line Dressing Changes         

Changing IV Administration Sets           

Maintaining Peripheral IV Catheter Patency        

Converting Continuous IV to IV Capped Lock    

Removing IV Cannula   

Ice Pack, Ice Collar       

Intake and Output         

Intravenous Infusion Rate          

Administration of Blood or Blood Products       

Blood Consent/Refusal Forms  

Standing Orders for Blood Filter Usage 

Transfusion Reaction    

Guidelines for Immediate Management of Transfusion Reaction  

Abnormal Test Results  

Collection of Blood for Type and Crossmatch   

Testing of Blood Storage Refrigerator Alarms    

Specimen Collection     

Clean Catch Urine Specimen – Adult      

Afternoon Care 

NT Suctioning  

Urinary Catheterization of Female Patient           

Urinary Catheterization of Male Patient   

Retention Catheter, Insertion of Female 

Retention Catheter, Insertion of Male     

Care of Patient With a Retention Catheter          

Removal of Retention Catheter  

Back Rub         

Complete Bed Bath      

Patient Showers           

Oral Hygiene and Dental Care   

Making An Occupied Bed         

Use of the Bedpan/Urinal          

Bedtime Care   

Applying Elastic Wrap  

Care of Casts   

Cast Cutting and Removal        

Application of T.E.D. Stocking 

Traction, Bucks Extension        

Warm Moist Packs       

Sterile Dressing Changes          

Oxygen Therapy           

Colostomy and Ileostomy         

Irrigation:  Colostomy   

Irrigating a Foley Catheter         



The Safety Program and Committee

The Safety and Security Management Plan

General Safety Rules

Safety and Security Orientation 

Safety and Security Inspection

Weapons in the Workplace       

Aggressor in the Center

Policy For Smoking

Grounds Maintenance   

Building Maintenance    

Pest Control     

Staff Safety Program   

Burns, Cuts and Punctures        



Patient Safety Program      

Pediatric Safety           

Volunteer Safety          

Visitor Safety

Safety in OR

Safety in Anesthesia

Safety in Pharmaceuticals         

Safety in Support Services       

Safety Education and Promotion Program         

Prisoners as Patients

Risk of Harm to Self and/or Others    


Safe Body Mechanics  

Side Rails and Body Straps      

Use of Protective Restraints 

Transporting the Patient Within the Facility         

Transporting on Patient Bed      

Wheelchair Safety        

Assisting Patient to Walk          

Assisting Patient to Car     


Safe Use of Electrical Equipment          

Interruption of Electrical Services          

Checking Electrical Receptacles

Elevator Inspections     

Defective Equipment and Instrumentation        

     The Use of Power Strips in Patient Care Rooms
Operating Room Designations as Wet or Dry Locations


Equipment Management Plan    

QA/PI in Equipment Maintenance    

Inspection Schedules   

Equipment Inspection Prior to Use        

Preventive Maintenance Program          

Scheduling Biomedical Safety Checks  

Medical Device Tracking – Implants

Safe Use of Sterilizers                          

Safety in Radiology Services    

Safety Requirements for Ultrasound Scanners   

Safety Requirements for Mammography

Monitoring Blanket and Solution Warmers

Proper Storage Consideration for Chemicals and Incompatibility Chart

Storage of Compressed Gases 

Safety Check Schedule for Gases and Vacuum Lines    

Medical Gas Precautions          

Anesthetic Gas Waste Management      

Accidents and Emergencies      

Safety Checking New Equipment          

Lockout-Tagout Energy Control Plan   

Relative Humidity-Equipment and supplies  



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Ambulatory Development


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