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 - 4 policies
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
Policy Name: 3364-86-017-00 – Employment of Resident Physicians Under Contract to Another Program
Description: (Minor revision of existing policy) Added – New document for GME review – USMLE step and/or COMLEX level scores.
Scope: College of Medicine M.D. Program
Comment Period: December 5, 2025 - January 5, 2026
Comment on this policy: 3364-86-017-00
Policy Name: 3364-86-042-00 Transitions of Care
Description: (Minor/Technical Revision of Existing Policy) Revision of policy to optimize clinical assignments in transitions of patient care.
Scope: College of Medicine & Life Sciences M.D. Program
Comment Period: November 24, 2025 - December 24, 2025
Comment on this policy: 3364-81-01
Policy Name: 3364-81-19 COMLS Quiz and Exam Review Policy
Description: (Minor/Technical Revision of Existing Policy)Revision of policy to optimize clinical assignments in transitions of patient care.
Scope: College of Medicine & Life Sciences M.D. Program
Comment Period: November 24, 2025 - December 24, 2025
Comment on this policy: 3364-81-19
UTMC - 23 policies
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
Policy Name: 3364-90-16 Medical Record Retention and Destruction: Disposal of Protected Health
Information
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 5, 2025 - January 5, 2026
Comment on this policy: 3364-90-16
Policy Name: 3364-133-04 Controlled Substances
Description: (Minor revision of existing policy) Clarified procedure regarding security of storage areas, removed reference to old
policies, added nurse leadership and loss identification/follow-up process. Updated
drug names. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 5, 2025 - January 5, 2026
Comment on this policy: 3364-133-04
Policy Name: 3364-133-01 Formulary System
Description: (Minor revision of existing policy) Clarified procedure regarding security of storage areas, removed reference to old
policies, added nurse leadership and loss identification/follow-up process. Updated
drug names. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 5, 2025 - January 5, 2026
Comment on this policy: 3364-133-01
Policy Name: 3364-133-104 Self-Administration of Subcutaneous Insulin with an Insulin Pump
Description: (Minor revision of existing policy) Updated procedure to clarify patient provided insulin and pharmacy dispensing of insulin
for CSII pump. Updated provider orders and documentation requirements. Provided
updated Filling Instruction Links for reference information. Other minor formatting
and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 5, 2025 - January 5, 2026
Comment on this policy: 3364-133-104
Policy Name: 3364-100-70-07 Ordering of Antineoplastic Agents
Description: (Minor revision of existing policy) Updated policy statement to add reference to the Electronic Medical Record ad EPIC
Beacon Module for physician orders. Procedure was updated to include Oncology Fellow
dual sign off documentation from the oncology attending. Updated consent, documentation,
education, and order requirements. Updated Filling Instruction Links for reference.
Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 5, 2025 - January 5, 2026
Comment on this policy: 3364-100-70-07
Policy Name: 3364-133-05 Floor Stock
Description: (Minor revision of existing policy) Updated policy and procedure to clarify responsible parties for floor stock and counts.
Updated request form documentation requirements. Other minor formatting and grammatical
changes.
Scope: University of Toledo Medical Center
Comment Period: December 5, 2025 - January 5, 2026
Comment on this policy: 3364-133-05
Policy Name: 3364-140-38 Selection Criteria for Renal Transplant Candidates
Description: (Minor revision of existing policy) Updated procedure to include patients must be willing to accept blood/blood products
during all phases of the transplant process. Other minor formatting and grammatical
changes.
Scope: University of Toledo Medical Center
Comment Period: December 5, 2025 - January 5, 2026
Comment on this policy: 3364-140-38
Policy Name: 3364-87-42 Documentation Standards
Description: (Minor revision of existing policy) Updated documentation requirements, health information management, and attestation
requirements. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 5, 2025 - January 5, 2026
Comment on this policy: 3364-87-42
Policy Name: 3364-133-34 Medication Storage
Description: (Minor revision of existing policy) Updated policy purpose and procedure to include storage, monitoring, patient safety
and regulatory requirements. Updated references to policies and the Ohio Revised
Code. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: December 5, 2025 - January 5, 2026
Comment on this policy: 3364-133-34
Policy Name: 3364-118-18 Hemodialysis Reverse Osmosis (RO) Water Quality
Description: (Reaffirmation of existing policy) Clarified and provided greater detail related to obtaining sample and cleansing the
sample port.
Scope: University of Toledo Medical Center
Comment Period: November 24, 2025 - December 24, 2025
Comment on this policy: 3364-118-18
Policy Name: 3364-143-15 Kobacker Center Playground
Description: (Minor/technical revision of existing policy) Clarified that only Child and Adolescent Psychiatric Hospitalization (CAPH) patients
at the Kobacker Center shall have use of the playground.
Scope: University of Toledo Medical Center
Comment Period: November 24, 2025 - December 24, 2025
Comment on this policy: 3364-143-15
Policy Name: 3364-100-35-05 UToledo Health Board Orientation and Education Program
Description: (Major revision of existing policy) Updated policy statement and purpose to elaborate on the board orientation and education
program. Updated procedure to clarify the program and provide understanding of governance
requirements. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: November 24, 2025 - December 24, 2025
Comment on this policy: 3364-100-35-05