Hospital Policy and Procedure Manual

Group I    Organization

1.1.0   Hospital Mission

1.1.1   Improving Organizational Performance Policy

1.1.2   Organizational Chart - School of Medicine

1.3.0   Organizational Chart - University Hospital

1.4.0   Medical staff committee functions and membership are outlined in the LSUHSC Bylaws

1.4.2   Ethics Committee

1.5.0   Departments

1.5.1   Information regarding Hospital Departments scope of services, workload data and staffing is provided in the Integrated Plan for Provision of Healthcare Services

Group II    Administrative

2.1.0   Policy Guidelines

2.2.0   Observation Bed Policy

2.4.0   Patient Valuables

2.5.0   Utilization Review

2.6.0   Use of Alias Name

2.6.1   Name Change

2.7.0   Employee Possession of Weapons on State Property

2.9.0   Transfer of Emergency Patients from other Hospitals

2.9.1   Transfer of Stable Patients

2.9.2   Helicopter Transported Patients(Received at LSUHSC-S)

2.10.0   Contract Approval

2.11.0   Access to Care

2.11.1   Treatment for Non Resident Patients

2.11.2   Managed Care Transfers into the Facility From Non-Contracted Providers

2.11.3   Nonresident Pediatric Patient Registration

2.11.4   Access To Emergency Service Within 250 Yards Of Main Campus

2.12.0   Approved Guidelines and Manuals

2.13.0   Adoption Protocol

2.15.0   Smoking Policy

2.16.0   Visitation Policy

2.17.0   University Hospital Dress Guidelines

2.18.0   Acquisition Of Equipment

2.18.1   Management Of Equipment Service and Maintenance and Repair

2.18.2   Single Vendor Contract Equipment Maintenance

2.19.0   Organizational Ethics

2.20.0   Prisoner patients

2.21.0   Fee Assessment for On-site Clinical Education / Training

2.21.1   Requirements for Clinical Rotations

2.22.0   Variance Reporting / Sentinel Events

2.23.0   Management of Patient / Visitor Complaint

2.24.0   Request for Educational Programs

2.25.0   Referral Policy for Post Discharge Services / Care

2.26.0   2008 Integrated Plan For Provision of Health Care Services

2.28.0   Photography, and the recording of Video, Audio, Cinematography of Patient

2.30.0   Certification, Registration and Licenses

2.31.0   Courtesy Beds

2.32.0   Vendor Solicitation

2.33.0   Authorization of Infant Release

2.34.0   Relinquishment of Newborn

2.35.0   Disclosure of Unanticipated Outcomes and Medical Errors

2.36.0   Notification of death

2.37.0   Consultation Policy

2.38.0   Patients on Non-LSU Patient Care Equipment

2.39.0   Increased Controls For Radioactive Sources

2.40.0   Free Care Determination Policy

2.41.0   Tissue Procurement, Storage, and Disposition

2.42.0   Patient Discharge Appeal Process for Medicare Patients

Group III    Human Resource Management

3.1.0   Orientation, Education and Training

3.1.1   Documentation of Response to Learning Needs

3.2.0   Staff Rights

3.3.0   Pregnant Workers in Radiation Areas

3.4.0   Staffing

3.5.0   Competency Assessment Program

3.6.0   Personnel Radiation Monitoring

3.7.0   Employee Time and Attendance

3.7.1   Educational Time and Attendance

3.9.0   Personnel Identification Badges

3.11.0   Employee Access To Care

3.12.0   Leave and Holiday Pay for Shift Employees

3.13.0   Employee Debriefing Counseling Policy

3.14.0   Behavior Expectations And Standards of Conduct

Group IV    Environmental Care

4.1.0   For Infection Control Policy and Procedure Manual go to link:

4.1.2   http://www.sh.lsuhsc.edu/policies/policy_manuals_via_ms_word/Infection_TOC.htm

4.12.0   Emergency Procedures for Dislodged or Missing Cesium Implants

4.50.0   Radiation Safety During Iodine Therapy Over 30 Millicuries

Group V    Planning and Providing Care

5.0.0   Planning and Providing Care

5.1.0   Patient and Family Education

5.1.2   Potential Food-Drug Interactions

5.1.4   Tutorial Services (Public School System)

5.1.5   Immunization Education and Documentation

5.2.0  

5.2.1   Point of Care Testing

5.2.2   Transport of Specimen via Pneumatic Tube

5.2.4   Infection Control Guidelines for all POCT Areas

5.2.5   Physician Performed Microscopy Procedure Guidelines

5.3.0   Nutritional Screening

5.4.0  

5.4.10   Personnel Authorized to Prescribe Medications

5.4.11   Guidelines for Physician Extender Prescriptive Authority

5.5.0   Abuse and Neglect

5.6.0   Abortion

5.7.0   Organ Procurement

5.7.1   Organ Donation After Cardiac Death (DCD) Protocol

5.8.0   Ambulatory Care Division

5.9.0   Patient Assessment

5.9.2   Anesthesia Care

5.10.0   Admission

5.10.1   Patient Identification Band

5.11.0   Patient Recall

5.12.0   Code 99 Resuscitation Team

5.12.1   Crash Carts

5.12.2   Cardiopulmonary Resuscitation Form

5.13.0   Latex Allergy

5.14.0   Patient Communication Needs

5.15.0   Restraints

5.15.1   Restraint of Behavioral Health Disorder

5.15.2   Restraint of Nonviolent Patient

5.16.0  

5.16.1   Informed Consent

5.17.0   Patient Rights and Responsibilities

5.18.0   Management of Pain via Continuous IV Infusion

5.19.0   DNR

5.20.0   Brain Death Evaluation

5.21.0   Withhold Life Sustaining

5.22.0   Advanced Directives

5.23.0   Continuum of Care

5.24.0   Discharge Policy

5.26.0   Management of Patients Receiving Conscious Sedation

5.27.0   Management of Violent and / or Committed Patients

5.28.0   Audiology Services

5.29.0   Substance Abuse

5.30.0   Reporting Critical Test Results

5.31.0   Pre Operative Verification Process

5.32.0   Surgical Site Marking

5.33.0   Time Out

5.34.0   Pain Management

5.35.0   Scope of Rehabilitation Services

5.36.0   Speech

5.37.0   Pastoral Care

5.38.0   Social Services

5.40.0   Post-Mortem Care

5.41.0   Patients Leaving AWOL without Notification/Permission

5.42.0   Fall Prevention Program

5.43.0   Patient Handoff

5.44.0   Adult Vaccination Program

5.45.0   Shock Treatment and Resuscitation Team (START)

5.46.0   Diabetes Educator

5.47.0   Anticoagulation Safety

Group VI    Information Management

6.2.0   Confidentiality, Security and Integrity of Information

6.3.0   Release of Information

6.3.1   Fax Policy for Transmitting Patient Information

6.3.2   Poison Control Center

6.5.0   Medical Records Content / Documentation

6.5.1   Accuracy and Timeliness of Record Completion

6.5.2   Abbreviations and Symbols

6.13.0   Verbal and / or Telephone Physician's Orders

6.14.0   Hospital Forms Review and Approval Process

6.15.0   Information Management Training

6.16.0   Hybrid Medical Record Policy

Group VII    Miscellaneous

7.1.0   Use of Animals for Research

7.3.0   Emergency Biomedical Coverage

7.4.0   Body Donation

7.5.0   Pager System

7.6.0   Autopsies

7.6.1   Coroner's Case

7.8.0   University Police

7.9.0   Posting of Announcements

7.10.0   Handling of Foreign Objects Considered Evidence, Removed from the of Patient's Body

7.11.0   Transportation Services (External)

7.12.0   Loaning and Borrowing Equip. Supplies

7.14.0   Management of Radiation Producing Equipment

7.15.0   Clinical Alarm System

7.16.0   Cellular Phone Use

7.17.0   Deliveries of Medical Devices and Supplies During Non-Standard Hours

Group VIII    Medication Use

8.1.0   Pharmacy Services

8.2.0   Prescription Pads

8.4.0   Allergy and Adverse Drug Reactions

8.5.0   Drug Samples

8.6.0   Medication Administration

8.6.1   Standard Administration Times

8.6.2   Duration of Drug Administration

8.6.4   High Risk Medication Protocols

8.7.0   Formulary System

8.7.1   Hospital Drug Storage and Control

8.7.2   Restrictions In The Use Of Special Drugs

8.8.0   Investigational Drug Use

8.9.0   Personnel Authorized to Prescribe Medications

8.9.1   Medication Order Information

8.9.2   Discarding Medications

8.9.3   Medication Requested on IT

8.11.0   Outpatient Prescription Availability

8.12.0   Medications Brought Into Hospital by Patients

8.13.0   Control of Medications

8.14.0   Use of Preferred Medications (Therapeutic Interchange)

8.15.0   Intravenous to Oral / Internal (IV to PO) Medication Switch Policy

8.16.0   Medication Assistance Program (Outpatient)

8.17.0   Drug Recall

8.18.0   Drug Shortage

8.19.0   Medication Administration Check (MAK)

8.20.0   Medications Administration Via the Interathecal Route

8.21.0   Medication Reconcilitation