Document Sample
					                            SANTA CLARA VALLEY MEDICAL CENTER
                          HHC Policy and Procedure Approval Request List
HHC DATE: January 12, 2011
DEPARTMENT(s): Santa Clara Valley Medical Center
   Policy #                                  TITLE                              DATE    *A/C/D/R-NC
SCVMC Administration
VMC 154.02       Continuing Medical Education (The Standards for
                 Commercial Support)                                            11/10      R-NC
VMC 300.0        Patient Identification (Verification)                          11/10        C
VMC 321.4        Patient Information, Health Care Staff Accessibility to        05/10      R-NC
VMC 321.6        Legal Medical Record: Definition and Standards                 11/10        C
VMC 360.03       Verification of Procedures, Non-Operating Room Settings        11/10        C
VMC 372.01       Code of Behavior and Management of Disruptive Behavior         11/10        C
VMC 560.10       Abuse and Neglect Suspected in Licensed Health Facilities      11/10        C
VMC 560.12       Process Server Procedures – Claims, Summons,
                 Complaints, and Subpoenas                                      10/10      R-NC
VMC 611.3        Hepatitis B Vaccination (HBVAC) Program                        10/10      R-NC
VMC 638.2        Clinical Research – Misconduct in Science, Investigating and
                 Reporting                                                      11/10        C
VMC 639.11       Anticoagulant Management Program                               08/10        A
VMC 647.1        Rental Equipment, Patient-Related                              09/10        C
VMC 647.3        Supply Impounds                                                10/10      R-NC

 Inpatient Nursing
 AD-11           Staffing Report Guidelines, Master                             12/10        C
 ASS-1           Standard For Inpatient Assessment                               9/10        A
 ASS-10          Post Operative Care, Interim Guidelines For                    12/10      R-NC
 ASS-11          Sleep Program                                                  11/10        A
 ASS-12          Post Transradial Approach To Cardiac Catheterization           10/10        A
                 Using The Compression Band, Guidelines For Care Of
                 The Patient With A
 GPP-13          Post Mortem Care And Medical Record Documentation               9/09      R-NC
 GPP-31          Capd, Standard Inpatient Order Form                            12/10      R-NC
 GPP-32          Capd 24 Hour Flow Sheet                                        12/10      R-NC
 GPP-33          Capd Peritoneal Dialysate Fluid Sample Collection              12/10      R-NC
 GPP-35          Peritoneal Exit Site And Catheter Care                         12/10      R-NC
 GPP-41          Capd Exchange Fresenius Stay Safe Exchange Set                 10/10      R-NC
 GPP-43          Capd Adapter Change To Patients Original System                10/10      R-NC
                 Discharge Prep
 ICP-9           Wound Care Procedure                                            1/09        C
 IVP-13          Blood, Blood Components And Blood Derivatives,                  9/10        C
                 Administration Of
 IVP-17          Blood Withdrawal From Intermittent Infusion Set                 7/10        C
 IVP-2           Vascular Access Devices; Specialized                           12/10      R-NC
 IVP-20          IV Lock, Peripheral Intermittent Infusion Set- (IV Lock),       7/10        C
                 Insertion And Maintenance Flush
 IVP-7           Baxter Colleague Volumetric Infusion Pump                       9/10      R-NC
 IVP-7.1         Blood Fluid Warmer                                              6/10        C
 MED-15          Mak Bar Coding                                                  9/10        A
 NP-15           Alternate Work Schedules/Waivers Of Overtime                    6/10        C
 NP-16           Eight Hour Shift/Shift Differential                             6/10        D
 NP-17           Overtime Meal Reimbursement                                    12/10      R-NC
 NP-18           Clinical Nurse Series Placement And Promotion (Registered      12/10      R-NC
 NP-20           Per Diem / Extra Help Nursing Staff                            12/10        C
                                                                                             Page 1 of 5
  Policy #                                TITLE                               DATE    *A/C/D/R-NC
NP-6            Abortion Procedure, Employee Objection To Participation In     6/10      R-NC
NP-7            Abortion Procedure, Employee Objection To Participation In     6/10      R-NC
PCE-20          Kangaroo Pump Enteral Feeding                                  6/10      R-NC
PCE-21          Pulse Oximeter N595                                            9/10      R-NC
PCE-4           Stryker Frame, Turning Of A Patient On A Wedge                 9/10        D
PCE-5           Temp Plus                                                      9/10      R-NC
QI-19           Nursing Services Patient Classification System Review         10/10      R-NC
                Committee Bylaws
QI-32           Age Specific Pediatric Care                                    5/10        D
QI-33           Age Specific Pediatric Care                                    5/10        D
RCP-11          Endotracheal Suctioning Using The Closed In-Line Suction      12/10      R-NC
RCP-5           Tracheostomy Care                                             12/10      R-NC
SAF-12          Radioactive Materials                                         12/10      R-NC
SAF-36          Heat And Cold Localized Treatment                              6/10        A
SAF-8           Safety: Nursing Units                                         12/10        C

Labor and Delivery
EMERG-6546- Fetal Distress                                                    11/10      R-NC
C/S-6546-6     “Prepping” A Patient For Cesarean Delivery                     11/10      R-NC
A-6546-75      Management Of Infants And Mother At Risk For Flight            11/10      R-NC
A-6546-68      Infant Security System                                         07/10        D
S-6546-21      Fetal Fibronectin Collection                                   11/10      R-NC
EMERG-8        Zoek Non-Inflatable Anti-Shock Garment (Niasg)                 11/10        C
MED-6546-12 Active Management Of Labor                                        11/10        C

Pediatrics / Pediatric ICU
AD-6515-12       Pediatric Pain Management                                    12/10        C
AD-6515-39       Appropriate Placement Of Pediatric And Adolesscent           11/10        C
AD-6515-13       Moderate Sedation                                            12/10        C
ATD-6531-1       Criteria For Admission                                       12/10        C
AD-6531-14       Guidelines For Documentationon The Pediatric Nursing Daily   12/10        C
EQ-6515-11       Airshield Radiant Warmer                                     10/10        D
GUGI-6515-2      Bard Urotrack Plus                                           10/10        D
GUGI-6515-21 Gastrostomy Feeding                                              10/10        D
GUGI-6515-20 Gavage Feeding                                                   10/10        D

Ambulatory & Managed Care
 ADMN-24        Schedule Management Policies and Procedures                   12/10      R-NC
 ASPL-04        Attendance/Sign In Policy                                     12/10        C
 DENT-02        Steam Sterilizer Policies-Dental Clinic                        5/01        D
 B-6549-17      Fetal Acoustic Stimulatory (FAS)                              12/10        D
 B-6634-003     Laboratory Testing Protocol                                    9/07        D
 B-6634-006     Diagnostic Testing & Studies                                   9/07        D
 PTCR-13        Documentation in the Patient Medical Record                   12/10      R-NC
 QICP-01        Annual Review/Updating of Charge Document                      2/06        D
 QICP-02        Charge Document Form: Elements of                              2/06        D
 SDED-04        Specialized Vascular Access Devices                           12/10      R-NC
 SDED-06        Support Procedure for Schedule Maintenance and Systems         8/03        D
                Training Problems
 SDED-07        Student Clinical Experience in Ambulatory and Community       12/10      R-NC
                Health Services
 SERV-13        Procedures Allowed/Not Allowed- Obstetrics/Gynecology         12/10        C
                                                                                           Page 2 of 5
 Policy #                            TITLE                               DATE    *A/C/D/R-NC
SERV-19     Procedure Allowed/Not Allowed- Ophthalmology Clinic          12/10        C
SERV-22     Procedures Allowed/Not Allowed-Podiatry Clinics              12/10        C
SERV-23     Procedures Allowed/Not Allowed -Urology Clinics              12/10        C
GDL-03      Documentation of Vital Signs and Growth Parameters in the    12/10      R-NC
            Pediatric Medical Record
GDL-06      Utilization Management Clinical Practice and Referral        12/10      R-NC
            Guidelines, Ambulatory Care
SOC-01      Standards of Care                                            12/10      R-NC
SOC-02      Standards of Patient Care for Clinic Visits                  12/10      R-NC
SOC-03      Standards of Patient Care for Appointments                   12/10      R-NC
SOC-05      Urinary Catheterization Policies                             12/10      R-NC
PFS-01      Administrative Assistant/Secretary                           12/10      R-NC
PFS-04      Advice/Triage Registered Nurse, Valley Connection (VC)       12/10      R-NC
PFS-05      Ambulatory Services Manager (ASM)                            12/10      R-NC
PFS-05.2    Ambulatory Services Manager (ASM), Valley Connection         12/10      R-NC
PFS-08      Aspect System Administrator/Project Manager, VC              12/10      R-NC
PFS-9       Assistant Nurse Manager (ANM) Performance Standard           12/10        C
PFS-12      Benefits Counselor, PACE Clinic                              12/10      R-NC
PFS-15.0    Clinic Nurse (RN) II                                         12/10      R-NC
PFS-16.0    Clinic Nurse (RN) III                                        12/10      R-NC
PFS-19.0    Community Worker/Courier, PACE Clinic                        12/10      R-NC
PFS-19.2    Community Worker-Lenzen                                      12/10      R-NC
PFS-23      CPSP/Ambulatory Services Public Health Nutritionist          12/10      R-NC
PFS-24      CPSP/Perinatal Health Educator                               12/10      R-NC
PFS-28      Director, Quality and Education Services                     12/10      R-NC
PFS-31      Health Care Analyst II, Quality & Education Services-ACHS     9/02        D
PFS-33      Health Education Specialist                                  12/10      R-NC
PFS-33.2    Health Education Specialist, PACE                            12/10      R-NC
PFS-40.2    Health Services Representative-Senior, Valley Connection     12/10      R-NC
PFS-42      Language Services Coordinator                                12/10      R-NC
PFS-44      Management Information System C40 Data Assistant, VHC        12/10      R-NC
            @ Lenzen
PFS-45      Manager, Quality & Education Services                        12/10      R-NC
PFS-48      Medical Admitting Clerk (MAC)-Senior, Referral Center         8/02        D
PFS-52      Medical Clerk Typist                                         12/10      R-NC
PFS-53.3    Medical Social Worker, PACE Clinic                           12/10      R-NC
PFS-54      Medical Translator                                           12/10      R-NC
PFS-59      Nurse/Information Services Aspect Coordinator,               12/10      R-NC
PFS-62      Office Specialist (Office Clerk)                             12/10      R-NC
PFS-62.1    Office Specialist III, Quality & Education                   12/10      R-NC
PFS-62.2    Office Specialist III, Community Collaborative Services      12/10      R-NC
PFS-69.1    Physician Assistant- Diabetes Center                         12/10      R-NC
PFS-74      Public Health Assistant                                      12/10      R-NC
PFS-75      Quality Improvement/Risk Management RN Coordinator           12/10      R-NC
PFS-81      Standards Coordinator, Q.I. Department                       12/10      R-NC
PFS-84      Resource Scheduler                                           12/10      R-NC
PFS-86.1    Medical Admitting Clerk I (MAC)-Supervising, Valley          12/10      R-NC
PFS-86.2    Medical Admitting Clerk II (MAC)-Supervising, VHC 2 Lenzen   12/10      R-NC
PFS-86.3    Health Services Representative I-Supervising                 12/10      R-NC
PFS-88      Specialty Health Center Manager                              12/10      R-NC
CCM-03      Central Catheter Management: Maintaining Patency and         12/10        D
            Heparin Irrigation of Capped Lumens
CCM-03.1    Central Catheter Management: Dressing/Tubing Change          11/07        D
CCM-03.2    Central Catheter Management: Blood Sampling                  11/07        D
EQP-03      Instrument Cleaning, Returning to Sterile Processing         12/10      R-NC
EQP-07      Steris System Sterilization                                  11/07        D
                                                                                      Page 3 of 5
 Policy #                              TITLE                                 DATE    *A/C/D/R-NC
EQP-12      Scope- Rhino-Laryngoscope, Instruction for Care-Handling          7/06        D
EQP-13      Scopes- Bronchoscope, Ureterscope and Cystoscope,                 7/06        D
            Instruction for Care-Handling
EQP-14      Scope- Evis Colonscope, Sigmoidscope and Gastroscope,             7/06        D
            Instruction for Care-Handling
GEN-05      Twelve Lead EKG                                                  12/10      R-NC
GUC-02      Urinary Catheter- Indwelling Insertion and Discontinuing         12/10      R-NC
GUC-04.1    Urinary Straight Catheter Insertion for Pediatrics (male &       12/10      R-NC
GUC-07      Supra-pubic, Care of and Change                                  12/10      R-NC
GUC-09      Urinary Instillations (Bladder Instillations)                    12/10      R-NC
GUC-10      Urinary Irrigations- Intermittent, Continuous (Clots, Sediment   12/10      R-NC
GUC-12      Uroflow Study & Post Void Residuals                              12/10      R-NC
IVB-01      Administration of IV Fluids                                      12/10      R-NC
IVB-03      Blood Cultures via Venipuncture                                   9/07        D
IVB-04      Suspected Transfusion Reaction                                    9/07        D
IVB-10      Phlebotomy Procedure                                             12/10      R-NC
LEGL-01     Seventy Two (72) Hour Detention Policy                           12/10      R-NC
OBG-02      Bartholin Cyst                                                   12/10      R-NC
OBG-05      Depo-Provera Procedure                                           12/10      R-NC
OBG-06      Hysteroscopy/Dilatation & Curettage                              12/10      R-NC
OBG-07      Intrauterine Insertion                                           12/10      R-NC
OBG-08      Laminaria Insertion                                              12/10      R-NC
OBG-10      Norplant Removal                                                 12/10      R-NC
OBG-11      Pelvic Exam Procedure                                            12/10      R-NC
PED-01      Audiometry Screening Procedure for Pediatric clinics             12/10      R-NC
PED-04      Immunization Documentation in the Immunization Registry          12/10      R-NC
            for Pediatrics
PED-05      ISHIHARA Test for Color blindness                                12/10      R-NC
PED-09      Vision Screening                                                 12/10      R-NC
PED-12      Dental Varnish, Application of                                   12/10      R-NC
RSP-02      Nebulizer Treatment Procedure                                    12/10      R-NC
RSP-03      Oral Airway Insertion                                             9/08        D
RSP-04      Oral/Nasopharyngeal Suctioning                                   12/10      R-NC
SDED-02     Basic Life Support (BLS) Training for Cardiopulmonary            12/10      R-NC
            Resuscitation (CPR), Pediatric Emergency Assessment,
            Recognition and Stabilization (PEARS) Training
SPC-05      Cytotoxic Wastes, Handling of                                    12/10      R-NC
SPC-05.1    Cytotoxic Spills, Small                                          12/10      R-NC
SPC-05.2    Cytotoxic Spills, Large                                          12/10      R-NC
SPC-07      Ear Irrigation                                                   12/10        C
WCP-09      Neurovascular Check of Cast/Injured Extremities                  12/10      R-NC
LVN-01      TB Test Administration and Screening Protocol for                12/10      R-NC
            Tuberculosis Control: Employee Health
BRN-39      Pediatric PPD Skin Test Protocol for School Admission            12/10      R-NC
SPC-11      Liquid Nitrogen Procedure                                        121/0      R-NC
WCP-01      Ace Wrap Procedure                                               121/0      R-NC
GEN-9       Fall Policy                                                      12/10        A
BRN-01      Anaphylaxis Protocol                                             12/10      R-NC
BRN-02      Acetaminophen Protocol                                           12/10      R-NC
BRN-06      Arthritis Clinic Patient Teaching Protocol                       12/10      R-NC
BRN-21      Employee Health Pre-placement Examination Protocol               12/10      R-NC
BRN-38      Phototherapy Clinic Protocol for Adult Dermatology Patients      12/10      R-NC
BRN-40      PPD Protocol for Primary Care Medicine Clinics                   12/10      R-NC
BRN-41.0    Prenatal First Initial Visit Protocol - CPSP                     12/10      R-NC
BRN-45      Review of Sputum Results- TB Clinic                              12/10      R-NC
                                                                                          Page 4 of 5
    Policy #                               TITLE                          DATE    *A/C/D/R-NC
  BRN-49        Antiemetic Administration Protocol                         4/03        D
  BRN-50        Emergency Contraception Protocol (Plan B)                 12/10      R-NC
  BRN-51        PPD (Purified Protein Derivative) Protocol in Pediatric   12/10      R-NC
                Primary Care Clinics.
  BRN-52        Procrit Administration Protocol                           10/05        D
  EHPNR09       Latex Sensitivity                                          6/07        D

Approved by Governing Board
Supervisor Liz Kniss, Chairperson
Health and Hospital Committee

*A= Add        C=Change       D=Delete         R-NC=Reviewed No Change

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