University Policy

Hospital Administration

HIPAA  policies 

3364-100-01-01 Admission, Discharge and Transfer
3364-100-01-02 Leave of Absence for Patients
3364-100-01-03 Patient Transportation to Other Health Resources
3364-100-01-05 Acceptance and Responsibility for Transferring Patients to the University of Toledo Medical Center
3364-100-01-07 Elective Admissions
3364-100-01-08 Room Assignment for Patients Undergoing Administration or Implantation of Therapeutic Radioactive Material
3364-100-01-09 Admission and Discharge Criteria for Special Care Units
3364-100-01-10 Observation Service
3364-100-01-11 Regional Access - Transfers
3364-100-01-12 EMS Bypass
3364-100-01-13 Confidential Patients
3364-100-01-14 Room Assignments for Patients Undergoing Administration of Intravenous Chemotherapeutic Agents
3364-100-01-16 Patient Identification
3364-100-01-17 Access to Care
3364-100-01-18 Notification of Hospital Discharge Appeal Rights
3364-100-01-19 Inpatient Same/Similar Name Alert
3364-100-01-20 Management of UTMC Inpatients Requiring Radiation Therapy at The Eleanor N. Dana Cancer Center
3364-100-01-21 Addressing Patients
3364-100-01-22 Protecting the Privacy of Patients During Medical Encounters
3364-100-05-01 Computer Downtime
3364-100-05-05 Medicare Questionnaire
3364-100-10-01 Consent to Treat and Informed Consent
3364-100-10-09 Consent for Human Immunodeficiency Virus (HIV) Testing
3364-100-10-10 Against Medical Advice: Informed Refusal/Withdrawal of Treatment or Leaving the Hospital
3364-100-10-12 Advance Medical Directives
3364-100-35-01 Designation of Authority During Absence of the Vice President/Executive Director
3364-100-35-05 Clinical Affairs Committee Informational Updates
3364-100-35-06 iCare Standards
3364-100-40-02 Management of the Health Care Worker Infected with Hepatitis B Virus, Hepatitis C Virus, or Human Immunodeficiency Virus
3364-100-45-01 Do Not Resuscitate Orders (DNRCC & DNRCC - Arrest) and Refusal of Life Sustaining Treatments
3364-100-45-02 Request for Determination of Death by Brain Criteria
3364-100-45-03 Organ, Tissue or Eye Donation after Death
3364-100-45-04 Care of Hospice Inpatient on Agency Services
3364-100-45-05 Rapid Response Team
3364-100-45-06 Code Blue Policy and Procedure
3364-100-45-07 Emergency Response for Health Science Campus 
3364-100-45-08 DNRCC & DNRCC - Arrest (DNR's) Temporary Suspension
3364-100-45-09 Blood Transfusion Reaction Protocol
3364-100-45-10 Code Blue Carts (Contents & Locations) 
3364-100-45-11 Proper Blood Transfusion Filter Use
3364-100-45-14 Suspected Child Abuse Neglect

3364-100-45-16 Adult-Elder Abuse, Neglect and Exploitation
3364-100-45-17 Lookback Program
3364-100-45-18 Assessment/Reassessment
3364-100-45-19 Pediatric Patients-Procedures
3364-100-45-20 Market Withdrawals/Recalls
3364-100-45-21 Domestic Violence
3364-100-45-22 Reporting of Animal Bites
3364-100-45-23 Involuntary Civil Commitment; Patients Lacking Decision-Making Capacity

3364-100-45-24 Hospital Clinical Alarms
3364-100-45-25 Urgent and Emergent Inpatient Intubation Pathway
3364-100-50-05 Organizational Business Ethics
3364-100-50-06 Accommodations for Patients Who Are Sensory Impaired and/or have Limited English Speaking Ability
3364-100-50-07 Reviews for External Review Agencies
3364-100-50-08 Hospital Department Grant Application
3364-100-50-10 Ambulance/Ambulette Services
3364-100-50-13 Prisoners-Patients Who Require Security Service Provided by a Law Enforcement Agency
3364-100-50-15 Dissemination of Medical Staff Members and Resident Credentialing-Related Information
3364-100-50-16 Management and Control of Agitated or Disturbed Persons
3364-100-50-21 Financial Policy for Organ Transplant Recipients
3364-100-50-22 Managing Staff Requests Not to Participate in Aspects of Patient Care
3364-100-50-23 Adjustment of University of Toledo Medical Center Charges
3364-100-50-24 Reimbursement for Patient Property
3364-100-50-25 Care of Patient Belongings and Valuables
3364-100-50-26 Trauma Alert System
3364-100-50-27 Scrubs - Authorized Use and Security
3364-100-50-30 Hospital-Wide Discharge Planning
3364-100-50-31 Approval of Standard Care Arrangements for Hospital Employed Advanced Practice Nurses
3364-100-50-32 Facsimile Transmission of Patient Information
3364-100-50-33 Cardiopulmonary Resuscitation Competency
3364-100-50-34 Critical Incident Debriefing
3364-100-50-38 Sentinel Events-Adverse Events
3364-100-50-39 Patient Safety Event and Incident Reporting
3364-100-50-42 Disaster Responsibilities for Volunteer Health Care Professionals
3364-100-50-43 Patient Status Assignment
3364-100-50-44 Warming Devices and Patient Safety
3364-100-50-46 Patient Complaint Monitoring
3364-100-50-47 COVID-19 Infection Control Procedures and Recommendations for the Operative Room(OR)
3364-100-50-48 Just Culture
3364-100-53-01 Transfer of Designation of Attending Physician
3364-100-53-02 Supplier Visitation to the OR
3364-100-53-03 Point-of-Care-Testing
3364-100-53-04 Reprocessing Medical Devices
3364-100-53-05 Universal Protocol Policy-Comprehensive Surgical Checklist
3364-100-53-06 Legal Medical Record
3364-100-53-11 Sedation-Analgesia by Non-Anesthesiologists
3364-100-53-12 Acute Care Restraint Policy
3364-100-53-15 Transfer of a Patient to Another Hospital
3364-100-53-17 Indications for Autopsy
3364-100-53-19 Horizon Patient Folder Electronic Signature
3364-100-53-20 Management of Obstetric Emergencies
3364-100-53-21 Requirements for Clinical Information on Laboratory Requisitions
3364-100-53-22 Critical Tests and Results
3364-100-53-23 Fecal Occult Blood Testing
3364-100-53-24 Emergency Medical Screening and Transfer
3364-100-53-25 ED Transitional Admissions
3364-100-53-26 Electronic Health Record (EHR) - Use of Templates and Copying Functionality
3364-100-53-27 Surgical Services Policy
3364-100-55-02 Procedures Which May Not Be Performed in the Emergency Department
3364-100-55-07 Emergency Medical Treatment for Employees

3364-100-55-08 Clinic Cancellations
3364-100-55-09 Patient with Massive GI Bleed Presenting to ED
3364-100-60-01 Complaint-Grievance Management
3364-100-60-02 Patient Rights and Responsibilities
3364-100-60-03 Notarization and Witnessing Services for Patients
3364-100-60-06 Adult Patients Requiring Psychiatric Intervention
3364-100-60-08 Right of Hospitalized Patients to Change Physicians
3364-100-60-10 Communication of Unanticipated Clinical Outcomes ("I'm Sorry Protocol")
3364-100-60-11 Personal Cell Phones/Pagers
3364-100-60-15 Patient Financial Support for Ambulatory, Outpatient care, Scheduled Surgical Procedures and Diagnostic Testing
3364-100-70-01 Obtaining Controlled Substances Without Certified Medical Indications
3364-100-70-02 Adverse Drug Reaction Reporting
3364-100-70-04 Drug Utilization Policies
3364-100-70-05 Therapeutic Drug Substitution
3364-100-70-07 Ordering of Antineoplastic Agents
3364-100-70-09 Drug Food Interaction
3364-100-70-10 Medication Management
3364-100-70-12 Medication Management Responsibility
3364-100-70-13 High Alert Medications
3364-100-70-14 Pneumonia and Influenza Standing Orders
3364-100-70-15 Medication Reconciliation
3364-100-70-16 Antimicrobial Stewardship
3364-100-70-17 Pain Management Stewardship
3364-100-85-02 Visitors Patients Accompanied by an Assistance Animal
3364-100-85-03 Visitor Authorization After Regular Hours
3364-100-90-19 Social Media
Last Updated: 6/23/23