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TTUHSC El PasoPolicy and Procedures

Policy and Procedures

All Campus Policies & Procedures (ACP) Click here

El Paso Policies & Procedures

Numerical Index






 Joint Commission E-dition


1. Leadership/Administration

EP 1.1    Mission Vision

EP 1.2    Clinical Dept Policies

EP 1.4    Diagnostic Study Results, Review of

EP 1.16   Smoke Tobacco Free Environment

EP 1.17   Clinical Trials Legal Documents

EP 1.18   Scheduling Research Participants 

EP 1.19   Budget Approval for Clinical Trials 

EP 1.19A Access Medicare Fee Schedule

EP 1.20    Study Closeout Procedures

EP 1.20A  Study Closeout Checklist

EP 1.21     Accounting Responsibilities Clinical Trials 

EP 1.22    Call Monitoring and Recording


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2. Emergency Procedures

All Campus Policies

2.03   Emergency Equipment: Crash Carts, Drug Boxes & Defibrillators

2.03A Crash Cart Supplies and Drugs

2.03B Emergency Equipment Check List

2.03C El Paso - Emergency Equipment Inventory

2.04   Bioterrorism Readiness Plan

2.04A El Paso - Contact Numbers

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El Paso Campus Policies

EP 2.1   Fire Safety Procedures

EP 2.2   Bomb Threat Procedures

EP 2.4   Robbery Situations - How Staff Must React

EP 2.5   Emergency Operations Plan

EP 2.6   Safety Program Management Plan

EP 2.7   Medical Emergencies in Clinical Areas

EP 2.7A Cardiopulmonary Arrest Flow Sheet 

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3. Patient Care

All Campus Policies 

3.05 Central Line

3.11 Extravasation Management

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El Paso Campus Policies

EP 3.1     Critical Laboratory Reporting

EP 3.2     Nursing Care, Standardization of

EP 3.3     Security of Abusable Supplies

EP 3.4     Supply-Medication Rotation

EP 3.5     Medications, Disposal of

EP 3.6     Admission and Transfer of Patients to Hospital

EP 3.7     Requisition Completion for Ancillary Service

EP 3.9     Pharmacy Calls to Clinics

EP 3.9A   Telephone Progress Note

EP 3.10   Universal Protocol Verification

EP 3.10A Universal Protocol Verification

EP 3.11   Anticoagulation Management Program

EP 3.12   Patient Assessment

EP 3.13   Assessment Treatment of Pain

EP 3.13A Pain Scales

EP 3.14    Patient Education

EP 3.15    Orders, Receiving and Noting

EP 3.16    Lab Specimen Collection

EP 3.17    Latex Allergy Protocol

EP 3.18    Removal of PICC Line

EP 3.19    Waived Testing

EP 3.19B  Quality Control Log

EP 3.20  Diagnostics Study Results Review of 2-2016
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4. Medication Management

All Campus Policies



El Paso Campus Policies

EP 4.1      Management of Clinic Stock Drugs

EP 4.1A    Medication Refrigerator Temperature Log

EP 4.2      Sample Drugs Control

EP 4.3      Medication Management, Administration & Documentation

EP 4.4      Medication Administration for CMA

EP 4.4A   Physician Delegation Statement

EP 4.4B   CMA Approved Medication List

EP 4.5     Prescription by Telephone

EP 4.6     Adverse Drug Event Reporting

EP 4.7     Intravenous Medication Administration

EP 4.8     Prescription Form Completion

EP 4.9     Multidose Vials

EP 4.11   Prescriptive Authority Policy

EP 4.11A Prescriptive Authority Agreement

EP 4.11B Clinic Review Log

EP 4.11C Hospital Review Log

EP 4.11D MTM Clinic Review Log

EP 4.12   Physician Delegation to Pharmacist


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5. Management of Information/Medical Record

All Campus Policies

5.01   Medical Records Documentation and Confidentiality

5.05.  Medical Records Form

5.12   Adoption Records


El Paso Campus Policies

EP 5.1    Medial Records Management

EP 5.2    Downtime Operations Guidelines

EP 5.2A  Downtime Operations Questionnaire

EP 5.2B  Downtime Progress Note

EP 5.3    Medical Records Access for Research

EP 5.4    Medical Records Request and Documentation

EP 5.5    Securing Medical Records Pending Litigation

EP 5.5A  Memo TT MR Dept to secure MR

EP 5.5B  Memo TT Ortho Dept to secure X-Rays

EP 5.5C  Memo TT BCC Dept to secure Mammograms

EP 5.5D  Memo TT OB-GY Dept to secure bone density records

EP 5.5E  Memo TT Psych Dept to secure Psych MR 

EP 5.5F  Memo TT Pediatric Dept to secure Psychotherapy 

EP 5.6 Proximity Cards 2-2016

EP 5.7    Medical Record Abbreviations

EP 5.7A  Do Not Use Abbreviations

EP 5.8    Authentication of Entries to Medical Record

EP 5.9    Access to the Medical Records Department

EP 5.10   Destruction and Disposal of PHI 

EP 5.11  Release of Health Record Information 

EP 5.12   Retention and Retirement of Medical Records 

EP 5.13   Medical Record Paper Format

EP 5.13A Medial Records Standard Format 

EP 5.15    Unsolicited Health Assessments in EMR

EP 5.16    Patient Portal Policy

EP 5.17 Medical Records Forms 6-2015

EP 5.18 Adoption Records 6-2015


6. Patient Rights/Patient Relationships and Agreements

All Campus Policies

6.04 Patients Who Threaten Harm to Themselves or Others

6.07 Clinical Research Patients

6.08 Spiritual Care

6.20 Advance Directives

6.20A Advance Directive Consent Form (English)

6.20A.1 Advance Directive Consent Form (Spanish)

6.20B Disclosure Statement for Medical Power of Attorney (English)

6.20B.1 Disclosure Statement for Medical Power of Attorney (Spanish)

6.20C Surrogate Decision of Advance Directives (English)

6.20C.1 Surrogate Decision of Advance Directives (Spanish)

6.20D Mental Health Declaration (English)

6.20D.1 Mental Health Declaration (Spanish)

6.20E Out of Hospital Do-Not-Resuscitate Order

6.20F Frequently Asked Questions Regarding Advance Directives

6.20G Advance Directives - Summary Sheet (English and Spanish)

6.21 Informed Consent

6.21A Consent for Treatment Guidelines, Who May Sign for Consent

6.21B Consent to Treatment/Health Care Agreement (English)

6.21B.1 Consent to Treatment/Health Care Agreement (Spanish)

6.21C Alternative Consent for Minor by Non-Parent

6.21D Texas Medical Disclosure Panel List A

6.21D.1 Texas Medical Disclosure Panel List B

6.21E General Medical/Surgical Procedures Consent (English)

6.21E.1 General Medical/Surgical Procedures Consent (Spanish)

6.23 Audiovisual Recording, Patient Consent

6.25 Transportation of Patients

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El Paso Campus Policies

EP 6.1    Patient Rights and Responsibilities

EP 6.2    Persons Accompanying Patients

EP 6.3    Termination of the Physician/Patient Relationship

EP 6.4    Management of the Suspected Abuse Victim

EP 6.4A  Recognizing and Reporting Child Abuse

EP 6.4B  Reporting Elder Disabled Abuse

EP 6.4C  Reporting Adult Victims Family Violence

EP 6.4D  Child Abuse Reporting Form

EP 6.4E  Notice of Family Violence

EP 6.5     Inmate Management Plan

EP 6.5A  Dealing with Prisoner Patients

EP 6.5B  Inmate Management Log

EP 6.5C  Instructions for Inmate Appointments

EP 6.5D  Inmate Management Policy Violation

EP 6.6    Patient Concerns

EP 6.7    Patient Feedback

EP 6.8    Refusal to Submit to treatment

EP 6.8A  Refusal of Treatment

EP 6.8B  Refusal of Treatment Español

EP 6.9    Family Participation in Patient Care Decisions

EP 6.10  Patients with Communication Impairment

EP 6.10  Suggestions Regarding Meeting Blind Person

EP 6.12 Photography Consent

EP 6.13 Transportation of Patients



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7. Infection Prevention and Control

All Campus Policies

7.02 Exposure Control Plan/Isolation Systems: Standard Precautions and Transmission-Based Precautions

7.04 Infection Control, Waiting Room/Lobby

7.07 Management of Blood & Body Fluid Exposures

7.07A Needlestick Injuries/Exposures to Body Fluids:(Amarillo)

7.07C Needlestick Injuries/Exposures to Body Fluids:(Lubbock)

7.07D Needlestick Injuries/Exposures to Body Fluids:(Odessa)

7.08 Cleaning of Blood Soiled Areas

7.09 Incidental Housekeeping

7.09 Sterilization Procedures, Autoclaves

7.11 Cleaning of Patient Exam Room

7.12 Storage of Linens and Supplies

7.15. High Level Disinfection for Reusable Instruments

7.15A CIDEX® OPA Test Strip Usage Instructions

7.16 Clinical Waste Disposal Procedures for Infectious Waste

7.17. Outbreak Investigation of Infectious Diseases

7.18. Plan to Manage the Influx of Potentially Infectious Patients

7.20 Employee Communicable Disease Policy

7.20A. CDC Personnel Health Guideline

7.20B . Employee Communicable Disease Report

7.21. Notifiable Conditions Reporting

7.22. Healthcare Associated Infection Tracking

7.22A Healthcare Associated Infection Communication Form

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El Paso Campus Policies

EP 7.1     Infection Control Screening: New Employee, Student, Visitor

EP 7.2     Standard Precautions for Blood/Body Fluids (Universal Precautions)

EP 7.3     Needlestick Injuries/Exposures to Body Fluids: Care and Follow Up

EP 7.3A   Exposure Control Plan, Bloodborne Pathogens

EP 7.4     Infectious Disease Exposures

EP 7.5     Immuno-Compromised Patients, Care of

EP 7.6     Chemical and Biological Monitoring of Stream Sterilization

EP 7.6A   Internal Pack (In-Pack) Monitoring of Steam Sterilization

EP 7.7      Tuberculosis Skin Testing Policy

EP 7.8     Notifiable Conditions Reporting

EP 7.9 Procedure for Notifying Custodial for Cleaning 11-2015

EP 7.10   Prevention of Transmission of Hepatitis B, C and HIV from HCW to Patient

EP 7.10A Expert Panel -OH Review and Decisions

EP 7.10B Patient Notification of Exposure

EP 7.10C Physician Attestation

EP 7.10D Exposure Prone Procedures Listing

EP 7.11   Vaccine Administration

EP 7.11A Vaccine Administration - Appendix D

EP 7.12   Infection Prevention & Control Plan

EP 7.12   Infection Prevention & Control Plan - Appendix A

EP 7.13   Influenza Vaccination

EP 7.14   Staff Lounge Cleaning

EP 7.15  Food in Clinical Areas

EP 7.16  Hand Hygiene

EP 7.17 Handling and Disposal of Needles/Sharps

EP 7.18  Disposal of Biohazard Waste

EP 7.19  Cleaning of Pediatric Toys and Equipment

EP 7.20 Sterilization of Reusable Instruments

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8. Performance Improvement

All Campus Policies

8.01 Performance Improvement Program

8.02 Occurrence Reporting

8.02A Occurrence Report Screen

8.07 Reporting Information to the National Practitioner Data Bank of the Texas Medical Board

8.10 Risk Management Plan

8.11 Termination of Physician & Patient Relationship

8.11A Sample Patient Termination Letter (English)

8.11B Sample Confirmation of Patient Decision to Transfer or Terminate Care (English)

8.11C Sample Patient Termination Letter (Spanish)

8.11D Sample Confirmation of Patient Decision to Transfer or Terminate Care (Spanish)

8.13 Missed Appointments/No Show Triage

8.13A Clinic No-Show Physician Triage, Pink Sheet

8.13B Missed Appointments Sample Letters (English)

8.13C Missed Appointments Sample Letters (Spanish)

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El Paso Campus Policies

EP 8.1 Performance Improvement Plan 1-2016

EP 8.1A Reporting Schedule

EP 8.1E Terminology 1-2016

EP 8.2    Management of a Sentinel Event

EP 8.2A Sentinel Event Root Cause Analysis 

EP 8.3 Risk Management Plan

EP 8.4 Occurrence Reporting

EP 8.4A Occurrence Report
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9. Management of Human Resources

All Campus Policies

9.10 Student Guidelines for Patient Care

9.21 Nursing Service Purpose, Philosophy and Objectives

9.23 Nursing Service Organizational Description and Standardization

9.24 License Verification: Registered Nurse, Licensed Vocational Nurse

9.25 Definitions and Limitations for GN, GVN & NA's

9.28 Clinical Personnel Dress Code

9.30 Resources Pool Staff

9.31 Nursing Budget Responsibilities

9.31A Annual Evaluation Format for Unit-Specific Staffing Plans

9.31B Nursing Management Report

9.50 Volunteer Program Philosophy, Objectives & Organizational Structure

9.50A Volunteer Rights and Responsibilities

9.50B Greeter

9.50C Clerical Assistant

9.50D Lab Assistant

9.50E Red Raider Reader

9.50F Clinic Assistant

9.50G Observer

9.50H Animal Therapy Program 


El Paso Campus Policies

EP 9.1   Verification of Licensure/Certification

EP 9.1A Verification of Licensure Form

EP 9.2   CPR Certification

EP 9.3   Mid Level Provider Requirements

EP 9.4   Lactation At The Workplace

EP 9.5 Dress Code Policy 10-2015

EP 9.6   Non Clinical Dress Code Policy

EP 9.7   Faculty/Staff/Resident Concern Procedures

EP 9.8   Students, Visitors on Campus

EP 9.9   Provider Onboarding Preparation 

EP 9.10 Provider Separation Procedure

EP 9.10A Physician Leaving Letter

EP 9.11 Clinical Dress Code Policy 11-2015

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10. Environment of Care

All Campus Policies

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El Paso Campus Policies

EP 10.1 Station on Emergency Eye Wash Shower and Flushing Stations Safety Standard Practice and Policy

EP 10.2 Fire Extinguisher Monthly Inspection - Off site Clinics

EP 10.3 Hazardous Material Emergency Plan

EP 10.4 Formaldehyde Safety Program

EP 10.5 Facility Use Committee

EP 10.6 Strange Odor Procedure

EP 10.7 Catering Safety

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