For more information about approved or retired policy documents, please note which manual the document belongs to and contact the appropriate Manual Owner as listed in the Manual Ownership Directory within Policy Manager. 

 

Approved Policy Documents	Manual
1:1 Observation / Constant Observation - Monitoring of Acute Medical Surgical and or Behavioral Health Patients	Clinical Interdisciplinary - Provision of Care, Treatment and Services
Admission, Transfer and Discharge - Perianesthesia and Perisedational Areas (Preop and Postop / PACU)	Clinical Specialty - Procedural Areas
Autopsy Criteria and Services	Clinical Interdisciplinary - Provision of Care, Treatment and Services
Brain Death	Health Affairs, Office of
Business Associate Agreements Policy	Healthcare Compliance & Privacy (OHCP)
Central Venous Access Devices - General Care, Dressing Changes, and Catheter Site Care	Clinical Interdisciplinary - Lines / Drains / Airways (LDAs)
Charges and Billing Procedures for Investigational Drug Services (IDS)	Pharmacy
Charter for Medication Safety IVMG Committee	Pharmacy
Cleaning, Disinfection, and Other Decontamination Steps	Clinical Specialty - Procedural Areas
Diasorin Aldosterone	Laboratory
Diasorin Elastase	Laboratory
Diasorin Renin Direct	Laboratory
DiasorinXL Calprotectin	Laboratory
Diazyme Human Kappa Free Light Chain Assay	Laboratory
Diazyme Human Lambda Free Light Chain Assay	Laboratory
EMTALA Policy	Clinical Specialty - Emergency Department (ED)
GYN Brachytherapy Applicator Sets - Cleaning and Sterilization Requirements	Clinical Specialty - Oncology & Cancer Center
Health Care Industry Representatives in Clinical Areas	Clinical Specialty - Procedural Areas
Hettich MIKRO 200R -- High Speed Microcentrifuge	Laboratory
High Level Disinfection	Clinical Specialty - Procedural Areas
Hospital Formulary System Policy	Pharmacy
IPAD / Camera Handling and Storage in Dermatology	Clinical Specialty - Dermatology
IV Infusion Service and Documentation Program	Pharmacy
IV Med Guidelines IV Push IV Titrate	Pharmacy
Loaned Instrumentation - Inventorying and Processing	Clinical Specialty - Procedural Areas
Medical Examiner's Case	Health Affairs, Office of
Medical Kidney for ARUP send out	Laboratory
Medication - Preparation, Labeling, and Maintenance on Sterile Fields	Clinical Interdisciplinary - Medication Management
Modalities (Rehab Services)	Clinical Interdisciplinary - Rehab Services (Occupational, Physical & Speech Therapy)
Neuromuscular Blocking Agents (NMBA): IV Administration in the Intensive Care Unit (ICU)	Clinical Specialty - Intensive Care Unit (ICU)
Nursing Responsibilities of the Radiation Oncology Nurse	Clinical Specialty - Oncology & Cancer Center
Organ and Tissue Donation	Health Affairs, Office of
Pain - Epidural Infusion and Patient Controlled Epidural Analgesia - Care of the Patient Receiving	Clinical Interdisciplinary - Provision of Care, Treatment and Services
Pharmacy Cleanroom Operations Policy	Pharmacy
Phototherapy - Care of the Patient	Clinical Specialty - Dermatology
Preoperative Type and Screen Nurse Driven Protocol	Clinical Interdisciplinary - Blood Administration
Process Verification and Quality Monitoring	Clinical Specialty - Procedural Areas
Rental, Demo, Loaner, and Other Non-Hospital Owned Patient Care Equipment used by JDH Staff	Facilities - Clinical Engineering
Reusable Articles Requiring Sterile Processing	Clinical Interdisciplinary - Infection Control / Epidemiology
Therapeutic Phlebotomy via Peripheral or Central Line	Clinical Interdisciplinary - Blood Administration
Tissue Management	Health Affairs, Office of
Transportation and Release of Bodies of Deceased Patients	Clinical Interdisciplinary - Provision of Care, Treatment and Services

 

Retired Policy Documents	Manual
B-type Natriuretic Peptide (BNP) by Architect	Laboratory
Discharge of Ambulatory Patients After Receiving Moderate / Deep Sedation and or Anesthesia	Clinical Specialty - Anesthesiology
Discharge Policies	Clinical Specialty - Anesthesiology
EMTALA - On-Call Obligations of Medical Staff Physicians	Clinical Specialty - Emergency Department (ED)
EMTALA - Qualified Medical Person	Clinical Specialty - Emergency Department (ED)
Fiberscope Care	Clinical Specialty - Oncology & Cancer Center
Intravesicular Chemotherapy and Biotherapy Administration	Clinical Specialty - Oncology & Cancer Center
Laser Procedures Guidelines	Clinical Specialty - Anesthesiology
Lasers - Intraoperative Use of	Clinical Specialty - Procedural Areas
Lyme QL3000 Procedure	Laboratory
Peripheral Nerve Stimulator / Train of Four Monitoring	Clinical Specialty - Intensive Care Unit (ICU)
Phototherapy PUVA Treatment	Clinical Specialty - Dermatology
Stericycle Medical Waste Process Flow	Facilities - Buildings & Grounds
Transitions of Care - Handover for Residents and Fellows	Health Affairs, Office of