See topics forPolicies
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.
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Approved Policy Documents |
Manual Name |
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Accounting Authority and Responsibility (Research / Sponsored Programs) |
Research |
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Admission Screening and Assessment for Initiating Airborne Isolation Precautions for Suspected or Confirmed Mycobacterium Tuberculosis |
Clinical Interdisciplinary - Infection Control / Epidemiology |
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Anaphylaxis Kits (Infusion Pharmacy Services) |
Pharmacy - Infusion Pharmacy Services (UHIPS) |
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Aptima SARS-CoV-2 Assay |
Laboratory |
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Aseptic Compounding Considerations (Infusion Pharmacy Services) |
Pharmacy - Infusion Pharmacy Services (UHIPS) |
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Barbituates by Alinity |
Laboratory |
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Beyond Use Dating (BUD) (Infusion Pharmacy Services) |
Pharmacy - Infusion Pharmacy Services (UHIPS) |
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Buprenorphine Urine Enzyme Immunoassay Alinity c |
Laboratory |
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Cleaning and Disinfecting of the Compounding Area (Infusion Pharmacy Services) |
Pharmacy - Infusion Pharmacy Services (UHIPS) |
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Cleaning of Patient Rooms - Inpatient |
Clinical Interdisciplinary - Infection Control / Epidemiology |
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Cleaning of Patient Rooms - Temporary |
Clinical Interdisciplinary - Infection Control / Epidemiology |
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Clinical Care of a Suspected of Confirmed Mpox Case |
Clinical Interdisciplinary - Infection Control / Epidemiology |
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Column Customizations - Tasks & Monitor Processes |
*Policy Manager Resources* |
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Consent and Conditions of Treatment Form (Spanish Version) |
Health Affairs, Office of |
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Coverslipping, Dermatopathology Procedure for |
Clinical Specialty - Dermatology |
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Daily Automated External Defibrillator (AED) Log |
Clinical Specialty - Ambulatory |
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Daily Inspecting of the LIFEPAK CR2 Automated External Defibrillator (AED) |
Clinical Interdisciplinary - Clinical Equipment |
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Delegation of Authority |
Laboratory |
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Destaining and Restaining Slides for Further Cytologic Evaluation |
Laboratory |
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Diasorin QuantiFERON |
Laboratory |
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Direct Billing (Research / Sponsored Programs) |
Research |
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Disclosure of Outcomes and Events |
Health Affairs, Office of |
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Eppendorf Mastercycler X50 |
Laboratory |
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Evacuation Plan (Pathology & Lab Medicine) |
Laboratory |
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Falls (Emergency Department) - Risk Identification, Prevention and Treatment |
Clinical Specialty - Emergency Department (ED) |
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Fentanyl Urine Enzyme Immunoassay Alinity C |
Laboratory |
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Financial Record Retention |
Research |
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FNA Using Hemacytometer Cover Glass as Spreader |
Laboratory |
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FNA Using Hemacytometer Cover Glass as Spreader Graphic |
Laboratory |
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Full Barrier Isolation Precautions Donning and Doffing Procedure |
Clinical Interdisciplinary - Infection Control / Epidemiology |
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Funding Under Letter of Credit Agreements |
Research |
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Handling of Fine Needle Aspiration Material by Trained Non-Cytology Personnel in Procedure Areas |
Laboratory |
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Handling of Proficiency Testing Failures |
Laboratory |
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Hazard Communication Program (Infusion Pharmacy Services) |
Pharmacy - Infusion Pharmacy Services (UHIPS) |
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Hepatitis B Core Antibody Total by Alinity |
Laboratory |
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Hepatitis B Surface Antigen (HBsAG) by Alinity |
Laboratory |
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Information Security Endpoint Protection and Software Update Policy |
Information Technology (IT) |
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Interim and Final Financial Reports |
Research |
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Laser / Energy Based Treatments in Dermatology - Care of the Patient |
Clinical Specialty - Dermatology |
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Local Anesthetic by Infiltration (Dermatology) |
Clinical Specialty - Dermatology |
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Mad Libs |
Interactive Training Session Documents |
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Management of Multi-Drug Resistant Organisms (MDRO) In the Home (Contact Precautions) (Infusion Pharmacy Services) |
Pharmacy - Infusion Pharmacy Services (UHIPS) |
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Manual Ownership Directory |
*Policy Manager Resources* |
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McFarland Standards Latex |
Laboratory |
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Mycobacterium Tuberculosis Exposure Control Plan (Infusion Pharmacy Services) |
Pharmacy - Infusion Pharmacy Services (UHIPS) |
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Mycobacterium Tuberculosis Exposure Control Policy & Procedure (Infusion Pharmacy Services) |
Pharmacy - Infusion Pharmacy Services (UHIPS) |
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New Lot Validation |
Laboratory |
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Observation Status |
Clinical Interdisciplinary - Case Management / Social Work / Utilization Review |
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Obstetrical Hemorrhage |
Clinical Specialty - OBGYN & Mother Baby Unit |
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Obstetrical Hemorrhage Toolkit |
Clinical Specialty - OBGYN & Mother Baby Unit |
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Organizational Structure (Infusion Pharmacy Services) |
Pharmacy - Infusion Pharmacy Services (UHIPS) |
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Outpatient Order Inquiry and electronic specimen collection |
Laboratory |
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Oxygen Therapy (Emergency Department) |
Clinical Specialty - Emergency Department (ED) |
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Patient Belongings |
Clinical Interdisciplinary - Provision of Care, Treatment and Services |
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Patient Owned Medication Pumps (Internal or External) - Management of |
Clinical Interdisciplinary - Clinical Equipment |
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Patient Valuables |
Clinical Interdisciplinary - Provision of Care, Treatment and Services |
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Personnel Training and Evaluation (Infusion Pharmacy Services) |
Pharmacy - Infusion Pharmacy Services (UHIPS) |
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Policy Writing Guide |
*Policy Manager Resources* |
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Preoperative and Preprocedural Management of Medications that may Affect Hemostasis Guidelines |
Clinical Interdisciplinary - Medication Management |
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QA-QC of Media and Reagents in Microbiology |
Laboratory |
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Quality Management Program |
Laboratory |
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Reporting Concerns Policy for Medical Residents and Fellows |
School of Medicine - Graduate Medical Education (GME) |
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Reporting of Critical Values |
Laboratory |
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Request Information Security Risk Assessment Procedure |
Information Technology (IT) |
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Requisition Entry - Entering Orders from a Submitter when the Patient is Billed |
Laboratory |
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Routine and Preventative Maintenance for Primary Engineering Controls (PEC) (Infusion Pharmacy Services) |
Pharmacy - Infusion Pharmacy Services (UHIPS) |
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Routine and Preventative Maintenance of Secondary Engineering Controls (SEC) (Infusion Pharmacy Services) |
Pharmacy - Infusion Pharmacy Services (UHIPS) |
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Routine Maintenance of Compounding Equipment (Infusion Pharmacy Services) |
Pharmacy - Infusion Pharmacy Services (UHIPS) |
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Six Elements of Competency |
Laboratory |
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Slide Retention and Filing of Slides and Reports |
Laboratory |
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Special Pathogen Employee Task Log |
Clinical Interdisciplinary - Infection Control / Epidemiology |
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Special Pathogen Procedures for Inpatient Units |
Clinical Interdisciplinary - Infection Control / Epidemiology |
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Special Pathogen Procedures in Ambulatory Clinic Areas |
Clinical Interdisciplinary - Infection Control / Epidemiology |
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Special Pathogen Procedures in the Emergency Department |
Clinical Interdisciplinary - Infection Control / Epidemiology |
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Special Pathogens Preparedness Policy |
Clinical Interdisciplinary - Infection Control / Epidemiology |
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TCL207.v1 - Process for Environmental Testing of the BMT Unit |
Clinical Specialty - Oncology & Cancer Center |
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TCL303.v2 - Informed Consent of the Autologous Transplant Patient |
Clinical Specialty - Oncology & Cancer Center |
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TCL602.v2 - Infection Control in the BMT Unit |
Clinical Specialty - Oncology & Cancer Center |
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TCLF012.v1 - BMT & Cellular Therapy Audit Report |
Clinical Specialty - Oncology & Cancer Center |
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TCLF015.v1 - BMT & Cellular Therapy Unit Daily Cleaning Log |
Clinical Specialty - Oncology & Cancer Center |
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Template Guide - Policy |
*Policy Manager Resources* |
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Template Guide - Procedure |
*Policy Manager Resources* |
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Transbronchial Fine Needle Aspiration |
Laboratory |
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Urinary Tract Cytology |
Laboratory |
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Use of Botox Injection for Axillary Hyperhidrosis |
Clinical Specialty - Dermatology |
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Vaso-occlusive (Sickle Cell) Crisis Emergency Department Clinical Care Guidelines |
Clinical Specialty - Emergency Department (ED) |
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Retired Documents |
Manual Name |
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Use of Collodion in EEG Testing |
Clinical Specialty - Epilepsy Monitoring Unit |
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Special Pathogens Preparedness Protocol |
Clinical Interdisciplinary - Infection Control / Epidemiology |
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VasoOcclusive Emergency Department Process Policy |
Clinical Specialty - Emergency Department (ED) |
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Quanta-Lyser 3000 / 4000 Module 1: Overview of System |
Laboratory |
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Quanta-Lyser 3000 / 4000 Module 2: System Operation |
Laboratory |
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Quanta-Lyser 3000 / 4000 Module 3: Reviewing and Confirming Results |
Laboratory |
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Quanta-Lyser 3000 / 4000 Module 5: Troubleshooting |
Laboratory |
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DPH Certificate ACC Exp.12.2023 |
Laboratory |
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Central Services Duties |
Laboratory |
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CAP Accreditation Certificate |
Laboratory |
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Financial Responsibility (Research / Sponsored Programs) |
Research |
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Procurement of Goods and Services (Research / Sponsored Programs) |
Research |