University Policy

Hospital Administration

 

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
3364-100-01-06 Inpatient Rehabilitation Admission to Coghlin Rehabilitation 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
3364-100-01-15 Admission and Discharge Criteria for Intermediate Care Units
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
3364-100-05-01 Computer Downtime
3364-100-05-02 Authorized Use of the Hospital Computer System
3364-100-05-04 Recurring (Monthly) Billing Patients
3364-100-05-05 Medicare Questionnaire
3364-100-05-06 Physician Non-Staff Caregiver Table Maintenance
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 & Procedure for Main Hospital, Heart & Vascular Center, Hospital Clinics and the George Isaac Outpatient Center)
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
3364-100-50-05 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
3364-100-50-20 Transplantation Patient Selection Committee
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
3364-100-50-35 Impounded Medical Charts
3364-100-50-38 Sentinel Events-Adverse Events
3364-100-50-39 Patient Safety and-or Occurrence Reporting
3364-100-50-41 Use of Utility Elevator
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
3364-100-50-45 Humidity in the Operating Rooms
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-Procedural Verification/Time Out
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
3364-100-53-16 Verbal Orders Including Telephone Orders
3364-100-53-17 Indications for Autopsy
3364-100-53-18 Handwritten Entries in the Medical Record, Signature Stamps and Electronic Signature on Transcribed Reports
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
3364-100-55-02 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
3364-100-60-01 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
3364-100-60-12 Patient Financial Support for Ambulatory and Outpatient Care
3364-100-60-13 Patient Financial Support for Scheduled Surgical Procedures and Diagnostic Testing
3364-100-60-14 Healthy Beverage Policy
3364-100-65-02 Licensure and or Certification Policy
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
3364-100-70-11 Use of Abbreviations in the Medical Record
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
3364-100-80-01 Statement of Purpose and Services, UTMC Rehabilitation Hospital
3364-100-85-02 Visitors Patients Accompanied by an Assistance Animal
3364-100-85-03 Visitor Authorization After Regular Hours
3364-100-90-01 Release of Health Information
3364-100-90-02 Minimum Necessary Guidelines for Use Disclosure of Protected Health Information
3364-100-90-03 Request for Restriction on Health Information
3364-100-90-05 De-Identifiable and Re-Identifiable Health Information, Limited Data Set and Data Use Agreements
3364-100-90-07 Medical Record Availability, Access and Amendment
3364-100-90-08 Patient Directory
3364-100-90-09 Joint Notice of Privacy Practices
3364-100-90-11 Accounting and Documentation of Disclosures of Protected Health Information other than Treatment, Payment or Healthcare Operations
3364-100-90-12 Security and Protection of Patient Information - Both Paper and Electronic
3364-100-90-13 Business Associate
3364-100-90-14 Photographing-videotaping, filming, video recording
3364-100-90-15 Reporting of Security Breach of Protected Health Information including Personal Health Information
3364-100-90-16 Medical Record Retention and Description; Disposal of Protected Health Information
3364-100-90-17 Medical Record Amendment
3364-100-90-18 Patient Request for Confidential Communications
Last Updated: 3/23/15