Policies Posted for Comment
Draft and recently signed policies are posted here for review and comment by The University of Toledo community for thirty days. Draft policies do not have official status as approved policies until the Approving Officer has signed the policies. Some policies may be signed in advance of the vetting period to comply with the requirement of federal or state laws or regulations or accrediting agencies.
Please direct any comments or questions regarding the policies posted for comment to policies@utoledo.edu or click on the icon under "comment on this policy." Please state the name of the policy in the subject line. Comments received on the policy will be forwarded to the policy's responsible agent or agent's designee.
To join our mailing list for email notification of updates and additions to the Policies Posted for Comment, please send an email to policies@utoledo.edu with "policies posted for comment" in the subject line.
NOTE: The University’s policies ultimately become a part of the Ohio Administrative Code. The Administrative Code is written in lower case. As each UT policy comes due for review, it will be formatted according to the Ohio Legislative Service Commission Drafting Manual. Many words that normally would be capitalized will not be capitalized in the text of the policy. For example – university of Toledo, president of the United States, supreme court, holidays such as Christmas day (Christmas is capitalized but day is not). The Drafting Manual includes many other grammatical guidelines. The header box and the signature box do not need to comply with these rules. Please do not send comments asking to revise capitalization, outline format, grammar, etc.
The following policies have been posted for the 30-day comment period:
College of Medicine & Life Sciences - 1 policy
Policy Name: 3364-86-028-00 – Patient Privacy/Confidentiality
Description: (Minor revision of existing policy) Additional guidelines for HIPAA including social media and non-HIPAA compliant artificial
intelligence applications.
Scope: College of Medicine M.D. Program
Comment Period: December 19, 2025 - January 19, 2026
Comment on this policy: 3364-86-028-00
UTMC - 21 policies
Policy Name: 3364-100-45-23 Involuntary Civil Commitment; Patients Lacking Decision-Making Capacity
Description: (Minor revision of existing policy) Updated language from Mentally Ill to a Person with Mental per the Ohio Revised Code.
Updated procedure to match current requirements for emergency hospitalization, liability,
and documentation requirements. Other minor formatting and grammatical changes.
Exhibit Documentation: DMHAS-0025 Application for Emergent Admission and DMHAS-0030 Affidavit of Mental Illness
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-100-45-23
Policy Name: 3364-124-04 Care of Specimens
Description: (Minor revision of existing policy) Updated Procedure to include that Specimen Disposition will be confirmed with the
attending physician during the procedure sign-out, at the end of the case. Other
minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-124-04
Policy Name: 3364-124-21 Storage of Sterile Supplies
Description: (Minor revision of existing policy) Clarified procedure statement removing temperature requirement for storage of sterile
supplies. Updated procedure to clarify action plan when humidity is out of range.
Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-124-21
Policy Name: 3364-124-66 Tissue Management
Description: (Minor revision of existing policy) Updated to reflect current tracking procedure and how to report through patient safety
net. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-124-66
Policy Name: 3364-135-01 Weight Limits of Imaging Tables
Description: (Minor revision of existing policy) Updated Weight limits of equipment based on manufacturer requirements. Other minor
formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-135-01
Policy Name: 3364-135-029 Timeliness of Critical Findings Reporting
Description: (Minor revision of existing policy) Updated timelines and criteria for notification of critical findings. Other minor
formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-135-029
Policy Name: 3364-135-095 Use of Radiation Protective Apparel when assisting in a procedure
Description: (Minor revision of existing policy) Minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-135-095
Policy Name: 3364-135-163 Pregnancy Screening prior to Nuclear Medicine Therapeutic Procedures
Description: (Minor revision of existing policy) Clarified pregnancy screening process. Updated scope to include timeline and other
relevant criteria. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-135-163
Policy Name: 3364-87-03 Medical Record Delinquency Policy
Description: (Minor revision of existing policy) Clarified expectation for provider signature within 24 hours for operative/procedure
report. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-87-03
Policy Name: 3364-101-109-01 University Counseling Center Billing for Services
Description: (New policy)
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-101-109-01
Policy Name: 3364-87-03 Medical Record Delinquency Policy
Description: (Minor revision of existing policy) Updated expectation for Operative/Procedure Report signature to be within 24 hours.
Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 19, 2025 - January 19, 2026
Comment on this policy: 3364-87-03
Policy Name: 3364-124-72 Cardiothoracic Surgery Services – Ages Served
Description: (Minor revision of existing policy) Updated language regarding ages served to match changes to the Ohio Administrative
Code. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 19, 2025 - January 19, 2026
Comment on this policy: 3364-124-72
Policy Name: 3364-100-50-32 Facsimile Transmission of Patient Information
Description: (Minor revision of existing policy) Updated the policy statement and purpose to clarify HIPAA and necessary guidelines
for disclosure. Updated purpose and procedure to reflect requirements for legal,
confidentiality, preventing and responding to errors. Other minor formatting and
grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 19, 2025 - January 19, 2026
Comment on this policy: 3364-100-50-32
Policy Name: 3364-100-10-12 Advance Medical Directives
Description: (Minor revision of existing policy) Updated the procedure to reflect changes to how the document is completed, how to
locate, storage, and other minor clarifications. Minor formatting and grammatical
changes.
Scope: University of Toledo Medical Center
Comment Period: December 19, 2025 - January 19, 2026
Comment on this policy: 3364-100-10-12
Policy Name: 3364-109-GEN-705 Vascular Access
Description: (Minor revision of existing policy) Updated the procedure to reflect changes to clinical indications for central venous
access. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 19, 2025 - January 19, 2026
Comment on this policy: 3364-109-GEN-705
Policy Name: 3364-100-60-11 Use of Electronic Devices (Cell Phones/Pagers/Mobile Devics) at UTMC
Description: (Minor revision of existing policy) Updated links to resources and policies. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 19, 2025 - January 19, 2026
Comment on this policy: 3364-100-60-11
Policy Name: 3364-100-85-03 Visitation of Patients
Description: (Minor revision of existing policy) Updated definition for the term “support person”. Updated procedure for completing
forms and clarified privacy, and other patient rights and concerns. Updated visitor
rules and regulations. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 19, 2025 - January 19, 2026
Comment on this policy: 3364-100-85-03
Policy Name: 3364-100-45-01 Do Not Resuscitate Orders
Description: (Minor revision of existing policy) Combined with policy 3364-100-45-08. Clarified providers who can complete an order,
how to document, and reference to the Ohio Department of Health forms that must be
completed. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 19, 2025 - January 19, 2026
Comment on this policy: 3364-100-45-01
Policy Name: 3364-87-06 Morbidity and Mortality Review
Description: (Minor revision of existing policy) Revised policy statement to clarify disposal, and destruction of protected health
information. Updated procedure to reflect new time frame for document retention:
11 years for adult patients and 25 for minors, from date of service. Updated reference
to the new electronic medical record, documentation, and electronic disposal requirements.
Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 19, 2025 - January 19, 2026
Comment on this policy: 3364-87-06
Policy Name: 3364-133-101 Daily Automated Dispensing Cabinet Transaction Report
Description: (Minor revision of existing policy) Updated the purpose of policy to remove specific pharmacy regulation. Added language
to cover all appropriate state and federal laws, and regulations. Other minor formatting
and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 19, 2025 - January 19, 2026
Comment on this policy: 3364-133-101