/policies/,

/policies/

201511307

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UWHC,UWMF,

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Policies

Policies -

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Location Policy # Link to Document Effective Date Last Modified Web Version
Electronic Media Handling, Destruction, and Disposal (1.06)
Lost & Found Articles (1.11)
Patient Status and Observation Patient Management (1.03)
Travel Expense Reimbursement and Reporting Requirements of Consultants and Contractors (1.32)
UW Health Credit Card Handling Policy (policy is used by UWHC and UWMF) (1.52)
UW Health Mobile Device Policy (this policy is used by UWHC, UWMF and UWSMPH) (1.46)
UW Health Non-Physician Observer Policy (this policy is used by UWHC, UWMF and UWSMPH) (1.48)
UW Health Secure Text Messaging via the Paging and Message Center (this policy is used by UWHC, UWMF and UWSMPH) (1.54)
Anesthesia Safety Equipment & Agents Regulations (12.19)
Chemical Hazard Communication Program (12.37)
Hazardous Materials and Gases/Radioactive Materials (12.25)
Hearing Conservation Program (12.56)
Personal Protective Equipment (12.44)
Reporting of Device-Related Adverse Events & other Product Problems (12.40)
Research Safety Committee Authority and Function (12.10)
Storage Policy (12.36)
Use of Wireless Communications and Control Devices (EMI) (12.23)
Charging System & Process for Charge Entry/Reconciliation for all UWHC Clinical Areas That Charge a Facility Fee (2.14)
Hospital Billing Policy (2.12)
Medical Item Procurement for Patients at Discharge (2.32)
Medicare as a Secondary Payor (2.28)
Moveable Capital Equipment Management (2.29)
Patient Right to Access Billing Records (2.24)
Reviews & Requests for Patient Information for Payment Purposes (2.22)
UW Health Charges for Patients in Research Studies (2.13)
Disinfection of Hospital Owned/Rented Equipment Prior to Serving or Shipping (13.31)
Restrictions on Food and Beverage Consumption (13.01)
Clinical Research Guidelines (4.24)
Investigational and Study Drug Control (4.11)
Release of Patient Information to News Media (4.16)
Signs (5.16)
Accounting of Protected Health Information Disclosures (6.23)
Communication with Patients Outside of the Clinical Setting (6.24)
E-Mail Transmission of Protected Health Information (6.31)
Notice of Privacy Practices (6.29)
Record Completion for Staff on Leave or No Longer Practicing (6.36)
Security of Faxed, Printed and Copied Documents (6.20)
Security of Paper Medical Records (6.21)
The Minimum Necessary Rule (6.30)
Transcription Confidentiality Policy (6.19)
Uses & Disclosures of Protected Health Info for Fundraising (6.34)
Uses & Disclosures of Protected Health Info for Marketing Purposes (6.33)
Credentialing and Professional Privileging of Advanced Practice Providers (8.75)
Peer Review for All Individuals Holding Clinical or Professional Privileges (8.39)
Safe Place for Newborns (8.01)
Health Facts For You (7.35)
Attendance and Punctuality (9.13)
Disciplinary Action: Non-Represented UWHC Authority Regular Employees (9.55)
Displaced Worker Policy (9.67)
Fitness for Duty: Impaired Employee (9.34)
Formal Appeal Process of Employee Discipline (9.54)
Home as Primary Work Site (9.61)
Internal Education & Training (9.19)
Multiple Employment Appointments Across UW Health (9.84)
Probationary Period (9.52)
Recording Paid Time (9.14)
Scheduling of Work (9.81)
Telephone and Cellular Phone Use (9.01)
Temporary Employees (9.49)
UWHC Seniority Awards (9.43)
Work Rules: UWHC Authority (9.04)
Workers’ Compensation: Alternate Assignment (9.33)
Workplace Violence Planning & Prevention (9.57)
Workplace Violence Reporting, Investigation & Discipline (9.58)
Purchase of Goods, Services, Equipment and Approval of Invoices (11.12)
Use and Oversight of Departmental Purchasing Cards (11.30)
8501 Excelsior Bomb Threat Policy (12.30)
8501 Excelsior Building Security (12.02)
8501 Excelsior Bulletin Board Policy (03 EX 8501)
8501 Excelsior Evacuation Policy (12.29 EX 8501)
8501 Excelsior Fire Response (12.27)
8501 Excelsior Package Delivery (01 EX 8501 )
8501 Excelsior Recycling (5.24 EX 8501)
8501 Excelsior Refrigerator Policy (04 EX 8501)
8501 Excelsior Tornado Policy (12.51 EX 8501 )
8501 Excelsior Visitor Policy (20 EX 8501 )
Ambulatory Policy and Procedure Format and Review (1.01)
Magazines/Publications in Waiting Areas/Exam Rooms (1.09)
Appointment Change/Cancellation - Ambulatory Services General (3.04)
Overhead Paging - East and West Clinics (4.15)
Security Managment Plan - Non-CSC Locations (4.03)
Tornado Response Plan (Tornado Alert) - Waisman Center/UWHC Clinics (4.64)
Insurance Referrals from Managed Health Care Plans (5.04)
Approval Process and Working Relationship between Preceptors and Nutrition Students (1.14)
Clinical Nutrition and UWHC Paging System (1.6)
Competency Assessment (1.3)
Human Milk and Formula Storage, Preparation and Distribution (1.9)
Malnutrition Practice Council Policy and Procedures (1.16)
On-Call Procedure (1.7)
Scheduling Procedures for Clinical Nutrition (1.8)
Scope of Practice for UWHC and AFCH Clinical Nutritionists, Registered Dietitians and Nutrition Technicians (1.1)
Adherence to Policy and Procedures (6.04)
Admission Requirements (6.07)
Assessment of Intern Learning and Performance (6.03)
Assessment of Prior Learning (6.08)
Dietetic Intern Access to Support Services (6.17)
Dietetic Internship Liability Insurance Requirements (6.15)
Dietetic Internship Privacy Policy (6.13)
Dietetic Internship Program Applications (6.01)
Discipline: Probation, Suspension, Termination (6.06)
Graduate Course Requirement for Dietetic Internship (6.05)
Guidelines for Travel (6.19)
Patient/Client and Employee Confidentiality (6.24)
Preceptor Orientation, Training and Evaluation (6.21)
Program Completion Requirements (6.14)
Program Cost and Budget (6.22)
Rotations, Supervised Practice and Educational Resources (6.26)
Student Records and Privacy (6.12)
Termination of Internship Experience (6.28)
UW Dietetic Internship Affiliated Agreement Process (6.27)
UWHC Dietetic Internship Grade Remediation Process (6.32)
UWHC Dietetic Internship Grievance and Complaint Process (6.09)
Work Hours and Absence Policy (6.02)
Worker’s Compensation and Liability (6.11)
Annual Verification of Registered Dietitian Professional and State Certificates (1.6)
Cleaning Responsibilities for Kitchen and Retail Spaces (1.01)
Guidelines for Participation in Off-Site Continuing Education Activities (1.5)
Guidelines for Sick Days (1.10)
Inservice Education Programs (1.09)
Protocol for Investigation of Food Borne Illness (1.02)
Quality Assurance (1.11)
Quarterly Check-ins (1.14)
Standards of Performance, Professionalism and Dress Code (1.08)
Stocking and Cleaning of Food in Patient Unit Kitchens and Family Lounges (3.16)
Vacation and Legal Holiday Selection and Time Off Process (1.07)
Cash Handling and Credit Card Procedure (4.01)
Culinary Services Credit Card Record Policy (4.03)
Delivery and Billing of Food Catering Services (6.01)
Inmate Meals (2.04)
Meal Delivery System for Patients and Guests (2.02)
Overnight Food Supply (2.07)
Fire Response in Food Production and Cafeteria Modules (3.16)
Food and Supplies Procurement for Departments Other Than Culinary Services (3.17)
Food Safety Practices (3.02)
Handing a Food Recall (3.25)
Pricing Food and Non-Food Items (3.20)
Annual Employee Orientation (F&E.10.10.01)
Attendance and Punctuality (F&E.10.10.02)
Development and Revision of Facilities and Engineering Services Policies (F&E.01.01.01)
Domestic Hot Water Standards (F&E.07.30.05)
Emergency Power Systems (EC.02.05.03)
Facilities & Engineering Biological (Pandemic) Event Procedure (F&E.04.10.11)
Facilities & Engineering Evacuation Policy (F&E.04.10.06)
Facilities & Engineering Medical Surge/Code White Plan (F&E.04.10.01)
Facilities & Engineering Services Safety Equipment (F&E.01.10.02)
Facilities & Engineering Services Snow Emergency Policy (F&E.04.10.05)
Facilities & Engineering Services “Code Pink” Plan for Infant/Child Abduction (F&E.04.10.08)
Fire Barrier Inspection and Maintenance (F&E.05.20.01)
Hazardous Substances Emergency (F&E.04.10.07)
Infection Control Policy (F&E.03.10.03)
Installing and Maintaining Appropriate Pressure Relationships (EC.02.05.01 EP6)
Interstitial Space Precautions (F&E.01.10.04)
Maintaining the Facilities & Engineering Services Logbook (F&E.01.10.06)
Mapping the Distribution of Utility Systems and Controls (EC.02.05.01 EP7,8)
Mercury-Containing Products Safety Plan (F&E.03.10.06)
Noise and Fume Precautions During Remodeling or Service Work (F&E.05.50.03)
Performance Evaluation and Work Planning (F&E.10.10.09)
Periodic Inspection and Preventative Maintenance of Electrical Distribution System (F&E.07.40.02)
Periodic Inspection of Line-Powered Equipment (F&E.06.20.08)
Pneumatic Tube System Cleanout Procedure (F&E.07.30.06)
Protecting PHI During Maintenance and Repairs (F&E.02.10.04)
Radioactive Material Safety Plan (F&E.03.10.02)
Scheduling of Facilities & Engineering Services Meetings (F&E.01.01.02)
Specifications for Extension Cords (F&E.07.40.01)
Testing and Installation of Medical Gas and Vacuum Pipeline Systems (EC.02.05.09 EP1-3)
Testing Battery-Powered Exits Signs & Egress Lights (EC.02.05.07)
Utility Equipment Management System (EC.02.05.01 EP2-4 EC.02.05.05 EP1, 3-5)
Utility Systems Failure Reporting (F&E.07.10.02)
Academic Improvement and Corrective Action (43.2)
Annual Institutional Review (AIR) (43.3)
Appeals of Resident Corrective Actions (43.4)
Appointment Information for Residents and Fellows in Graduate Medical Education Programs (43.24)
Evaluation of Residents and Faculty (43.7)
GME Disaster Management (43.5)
Graduate Medical Education Institutional Commitment Statement (43.26)
Gradute Medical Education Committee Charge (43.25)
Impaired Residents: A Summary of Key Policies and Procedures (43.9)
Program Closure or Reduction (43.12)
Promotion of Residents (43.13)
Recruitment and Selection of Residents and Fellows (43.16)
Resident Absences and Leaves (43.1)
Resident Grievances Related to Employment Concerns (43.8)
Resident Off-site Elective Rotations (43.15)
Resident Position Requests for New and Existing Programs (43.11)
Resident Use of Legal Name, Name Changes, and Credentials (43.23)
Restrictive Covenant Prohibition (43.17)
Standardization, Security and Retention of Resident Files (43.14)
Stipend Administration for GME Trainees (43.18)
Supervision of Residents (43.19)
Training and Certification for Central Vascular Access Devices ("CVADs") (43.20)
Transitions of Care / Handoff Policy (43.22)
Work Hours and Moonlighting (43.27)
CareLink Downtime (HL-020-POL)
Charge Router Change Management (HL-008-POL)
Device Management – LWS Workstation Record (HL-016-POL)
Emergent or Canceled Production Downtime (HL-019-POL)
Environments (HL-013-POL)
Master File Maintenance EAP (HL-001-POL)
Master File Maintenance Willow (HL-006-POL)
Patient Safety Escalation (HL-009-POL)
Print Queue and Device Management Policy (HL-003-POL)
RA SU Management (HL-010-POL)
Restricted Master File Access (HL-017-POL)
Retriggering Charges (HL-015-POL)
RightFax Management (HL-011-POL)
Sharing Health Link-Based Intellectual Property (HL-022-POL)
SuperUser SmartTools Access (HL-021-POL)
Test Patient Creation in Production (HL-005-POL)
UW Health Batch Schedule Request (HL-023-POL)
UW Health IS Business Continuity and Risk Management Policy (AD-POL-006)
Activating Health Link RightFax in the Non-Production Environments Procedure (HL-011-PRO-2)
CareLink Downtime Procedure (HL-020-PRO)
Charge Router Change Management Procedure (HL-001-PRO)
Emergent or Canceled Production Downtime Procedure (HL-019-PRO)
Master File Maintenance EAP Procedure (HL-001-PRO)
Device Management – LWS Workstation Record Procedure (HL-016-PRO)
Environments Procedure (HL-013-PRO)
Master File Maintenance Willow Procedure (HL-006-PRO)
Patient Safety Escalation Procedure (HL-009-PRO)
Restricted Master File Access Procedure (HL-017-PRO)
RA SU Management Procedure (HL-010-PRO)
Retriggering Charges Procedure (HL-015-PRO)
RightFax Management Procedure (HL-011-PRO-1)
SuperUser SmartTools Access Procedure (HL-021-PRO)
UW Health Batch Scheduling Request Procedure (HL-023-PRO)
Sharing Health Link-Based Intellectual Property Procedure (HL-022-PRO)
Test Patient Creation in Production Procedure (HL-005-PRO)
UW Health Batch Scheduling Best Practices -- Text Navigation and Jobs (HL-024-PRO)
UW Health Batch Scheduling Best Practices - Tips and Tricks (HL-025-PRO)
Business Continuity and Risk Management (AD-POL-006)
Change Review and Management (AD-POL-002)
Computer and Server Decommissioning (IN-PRO-009)
Computer Security Incident Response (SE-POL-002)
Consultant Hiring (AD-POL-008)
Credit Card Security (SE-POL-004)
Credit Card Use (AD-POL-004)
Customer Service (AD-POL- 003)
Data Center Access (IN-POL- 001)
Director On Call (AD-POL- 015)
Elevated Privileges (SE-POL-005)
IS Requisitioning (AD-PRO-016)
Monitoring Systems and the Network (IN–POL-010)
Network Equipment Management (IN-POL-004)
New Employee Setup (AD-PRO- 007)
Out of Office Request (AD-POL-010)
Policy and Procedure Development (AD-POL-001)
Problem Review (SE-POL-003)
Project Management (AD-POL- 011)
Software Development Life Cycle Policy for Cardholder Data Environment (SE-POL-007)
System Downtime (AD-POL-005)
System Maintenance and Management (IN-POL-011)
Systems Backup (IN-POL-002)
Systemwide Malware and Antivirus (IN-POL-005)
Telecommuting (AD-POL- 014)
Testing and Troubleshooting (AD-POL-017)
Time Tracking (AD-POL-012)
Vacation and Holiday Selection and Scheduling (AD-POL-013)
Computer Security Incident Response Procedure (SE-PRO-002)
Consultant Hiring Procedure (AD-PRO-008)
Credit Card Use Procedure (AD-PRO-004)
Customer Service Procedure (AD-PRO- 003)
Data Center Access Procedure (IN-POL-001)
Director On Call Procedure (AD-PRO- 015)
Monitoring Systems and the Network Procedure (IN–PRO-010 )
Network Equipment Management Procedure (IN-PRO-004)
New Employee Setup Procedure (AD-PRO-007)
Out of Office Request Procedure (AD-PRO- 010)
Policy and Procedure Development Procedure (AD-PRO-001)
Problem Review Procedure (SE-PRO-003)
Project Management Procedures (AD-PRO-011)
System Downtime Procedure (AD-PRO-005)
System Maintenance and Management Procedure (IN-PRO-011)
Systems Backup Procedure (IN-PRO-002)
Systemwide Malware and Antivirus Procedure (IN-PRO-005)
Time Tracking Procedure (AD-PRO-012)
Delivery of Patient Care Unit Equipment (Adult & Pediatric) (6.28)
Guidelines for Placing Patients Off Service and Returning Adult Patients to Their Home Unit (6.34)
Locked Bathroom Access (6.32)
Processing Patient Care Orders (6.29)
Nursing Committee Structure (2.10)
Nursing Administrative Policy and Procedure Committee (2.35)
Nursing Patient Care Procedures Committee (2.36)
Nursing Product Evaluation (2.37)
Quality Improvement at the Unit and Clinic Level (2.31)
Cardiac Rhythm Interpretation Testing (3.16)
Clinical Certification Policy for Nursing (3.18)
Conducting Nursing Research at UWHC (3.23)
Department of Nursing Competency Assessment Process, Adult and Pediatric (3.25)
Nursing Continuing Education and In-Service Guidelines for UWHC Programs (3.14)
Nursing Continuing Education Contact Hours (3.15)
Off-Site Education (3.12)
Registered Nurse Orientation (3.13)
Requirements for Completion of Basic Critical Care Orientation - Inpatient Adult (3.17)
Research: Obtaining Nursing Resources and Support (3.11)
Reference Materials for Clinical Nursing Staff (3.19)
Spiritual Care (7.12)
Management of Mercury Spills (7.15)
Convenience Cards (7.16)
Guidelines for the Integration of Nursing Responsibilities in Decentralized Program Areas (1.17)
Scope of Service and Nursing Care (1.19)
Changing or Establishing Charges for New Procedures and Care Provided by Nurses on the Inpatient Units (9.01)
Charging Patients for Medical Supplies Used During a Patient Stay on an Inpatient Unit (9.15)
Criteria for Bariatric Increment Charge on Adult and Pediatric Inpatient Units (9.02)
Criteria for ICU Singles Charge for Patients Receiving 1:1 Care in an ICU Setting (9.03)
Criteria for Inpatient Daily Care Level 5 Charge - Adult Inpatient Tracheostomy Patients (9.09)
Criteria for Inpatient Daily Care Level 5 Charge - Flap or Replant Patients (9.08)
Criteria for Inpatient Daily Care Level 5 Charge - Patients who have sustained a Neurological Insult (Includes traumatic brain injury and other) (9.06)
Criteria for Inpatient Daily Care Level 5 Charge - Urology Surgery (Cystectomy) Patients (F66 Only) (9.16)
Criteria for Inpatient Daily Care Level 5 Charge Pediatric Patients who have sustained a Neurological Insult (includes traumatic brain injury and other) (9.04)
Criteria for Inpatient Daily Care Level 5 Charge Spinal Cord Injury Patients (9.05)
Criteria for Inpatient Daily Care Level 5 Charge – Gynecology Oncology Surgery Patients (F66 Only) (9.14)
Criteria for Inpatient Daily Care Level 5 Charge: Pediatric Compromised Airway Patients (9.07)
Criteria for Inpatient Daily Care Level 6 - Post Transplant Patients (9.11)
Criteria for Singles Charge for Patients Receiving 1 to 1 Care not in an ICU Setting (9.10)
IMC Criteria for Hematopoietic Stem Cell Transplant (HSCT) - B6/6 (adult) or P4 (pediatric) (9.17)
Inpatient Daily Care Charges for the CT-Surgery Acuity Adaptable Unit (9.13)
Patient Charge Capture Responsibilities on the Inpatient Units (9.00)
Annual Peer Review and Colleague Review for Professional Nurses (4.60)
Attendance (4.10)
Clinical Overload Nurse (4.34)
Communication During Weekend and Holiday Coverage (4.39)
Expansion Staff Working Extra Hours (4.33)
Graduating RN Functioning in a Non-RN Patient Care Position (4.66)
Nursing Clinical Advancement Program (NCAP) (4.65)
Nursing Vacation Policy (4.62)
Per Diem Nurse Clinician Scheduling of Work (4.63)
Resignation and Transfer Notice (4.46)
RN/LPN License Verification (4.12)
Scheduling of Work (4.61)
Student Clinical Practice of Nursing and Advanced Practitioners at UW Health (8.11)
Overtime Hours for Contracted and Agency Nursing Staff (5.11)
Preparing a Continuity of Care Referral for an Inpatient Discharge (Adult & Pediatric) (14.19)
Transfer of the Patient (Adult & Pediatric) (14.17)
Activities of Unlicensed Pharmacists and Pharmacy Students (1.13)
Administrative Standards (1.7)
Department of Pharmacy Compliance with Laws and Regulations Pertaining to Practice of Pharmacy (1.3)
Directions - HL, Mobile Meds, and or Connect-Rx Downtime (1.27)
Distribution and Use of Medication Dispensing Pins (1.41)
External Disaster and Multiple Victim Trauma Response (MVTR)Plan (1.21)
Guidelines for Use and Security of Department Owned Laptop Computers (1.34)
Handling of Check Payments for UWHC Transactions (1.16)
Management of Pharmacy Department Policies (1.22)
Management of Pharmacy Keys (1.45)
Management of Technician Sick Call (1.9)
Medication Pricing Policy (1.20)
Medication Refrigerator Audit Policy (1.32)
New Employee Orientation and Training (1.6)
Orderliness and Cleanliness Guidelines - Central Pharmacy (1.40)
Payment to Pharmacists for Extra Shifts and Night Shift Incentive (1.39)
Pharmacist Advancement and Recognition Program (1.12)
Pharmacist CPR, ACLS, PALS, Certification (1.18)
Pharmacist Licensure and Certification Requirements (1.5)
Pharmacist Staffing/Scheduling (1.11)
Pharmacy Administrator On Call (1.10)
Pharmacy Personnel Budget Management and Position Control Systems (1.44)
Pharmacy Retention Records (1.23)
Pharmacy Staff Professional Meeting and Travel Policy (1.17)
Process for Requests and Approvals of Inpatient Clinical Pharmacist Project Time (1.15)
Production and Distribution of Pharmacy Reminder Notes (1.30)
Regulatory Compliance Inspections (1.19)
Security Management Systems for Medication Storage, Preparation and Dispensing Areas for UWHC (1.29)
Storage, Handling, Security and Disposition of Medications (1.43)
Student Employee Expectations (1.8)
Use of the Pharmacy Department Credit Card – Fact Sheet (1.46)
Verification of Prescribing Privileges (1.4)
Cash Handling Procedure (2.4)
Retail Pharmacy Copayment Collection (2.5)
UW Health Pharmacy Discount Policy (2.1)
Health Link Price Update (5.2)
Preparation of Liquid Unit Dose Product from Bulk Controlled Substances (7.19)
Disciplinary and Corrective Action for Residents (18.2)
Early Commitment Process for University of Wisconsin PGY1 Pharmacy Residents (18.10)
Extended Leave of Absence - Pharmacy Residents (18.8)
PGY1 and PGY2 Pharmacy Resident Paid Time Off (18.12)
Pharmacy Resident Duty Hours and Moonlighting (18.5)
Pharmacy Resident Pharmacy Practice Experience (18.1)
Residency Advisory Committee (18.4)
Resident Candidate Recruitment, Selection, and Interviewing Procedure (18.3)
Resident Major Project Requirements Policy (18.7)
Resident Objectives for Resident Checkout and Certificate (18.6)
Resident Professional Interview Days (18.11)
Resident Scheduling for Professional, Practice and Leisure (18.9)
Guidelines for Art at UWHC Facilities (PDC )
Guidelines for UWHC Interior Paint Selections (PDC)
Radiology Vacation and Legal Holidays (1.05)
Removal of Data from Decommissioned Storage Devices (1.03)
Cleaning & Changing of Patient Care Equipment (1.40)
Convenience Cards for Respiratory Therapists (1.18)
Emergency Plan For Loss Of Piped Gas Pressure (1.25)
Equipment Quality Assurance (1.59)
Flexing Staff to Work Volumes (1.06)
Multi Victim Trauma Response (1.28)
Orientation and Continuing Education (1.17)
Patient Care Hospital Emergencies and Internal Disasters (1.24)
Respiratory Care Response to External Disaster (1.27)
Respiratory Therapy Councils (1.23)
Respiratory Therapy Department Policies and Scope of Services (1.01)
Respiratory Therapy Vacation Policy (1.22)
Safety Standards for Medical Gases (1.26)
Scheduling and Time and Attendance (1.05)
Training and Travel Reimbursement (1.07)
Verification of Licensure (1.03)
Charge/Position on PM's, Nights and Weekends - UH and AFCH Operating Room (1.01)
Daily Audit of Emergency Carts - Surgical Services (1.05)
Identifying, Managing, and Preventing Disruptive Behavior by Medical Staff (1.23)
Medical Devices FDA Tracking in Perioperative Areas (1.37)
Operating Room Inventory Management (1.38)
Outpatient Surgery Center PACU Staffing Plan (1.21)
Outpatient Surgery Center Staffing Plan - OR (1.13)
Parking Permit Usage When On-Call (1.17)
Pharmacy Coverage in the Main OR (1.19)
Pharmacy Services: Outpatient Operating Room (1.20)
Prisoners, Care of in the Outpatient Surgery Center (1.36)
Scheduling and Management of Operating Room Cases (1.25)
Surgical Services Billing Policy (1.54)
Tornado Alert Plan - Operating Room (1.29)
UH Intraoperative Staffing Plan - Inpatient (1.26)
Case Cart/Doctor Preference Card Verification (2.06)
ABO & Other Vital Data Verification of Deceased Donor and Intended Recipient Prior to Organ Procurement (3.59)
ABO Verification of Transplant Recipients and Living Donors Prior to Transplant (3.60)
Accepting and Scheduling New External Post-Transplant Patients (3.47)
Adding Patients to the UNOS National Waitlist (3.09)
Coordination of Organ Transplants (3.14)
Data Management and Source Documentation Policy (5.0)
Determination of Medical Urgency for Kidney Transplantation (1.23)
Disease Transmission Reporting Policy (3.21)
Donor Vessel Recovery, Transplant and Storage Policy (3.52)
Financial Screening for Transplant Patients (3.2.26)
Increased Risk Donor Organ Policy (3.10)
Management of Patients During Inpatient Stay and Discharge – Abdominal Transplant (3.16)
Management of Patients During Inpatient Stay and Discharge – Cardiopulmonary Transplant (3.16.2)
Management of Patients Post-Transplantation (3.18)
Managing Patients on Wait List (3.12)
Multidisciplinary Patient Care Team (3.39)
Patient Consent Process (3.06)
Patient Evaluation and Selection Process (3.33)
Policy Development and Maintenance (3.01)
Prescription Renewal (3.36)
Referring Physician and Local Provider Communication Plan (3.04)
Removal of Patients from the UNOS National Waitlist (3.05)
Reporting of Post-Transplant Patients (3.20)
Transplant - Histocompatibility Lab Crossmatch Agreement (3.51)
Live Kidney Donor Selection and Evaluation Process (4.33)
Living Donor Advocate Process (4.48)
Living Liver Donor Selection & Evaluation Process (5.33)
Management of Patients During Inpatient Stay - Living Donor (4.16)
Multidisciplinary Patient Care Team: Living Donor (4.39)
Multidisciplinary Patient Care Team: Living Donor Liver (5.39)
National Paired Kidney Exchange Program (6.11)
Non-Directed Living Kidney Donation (4.50)
Post Donation Monitoring of Live Kidney Donors (4.18)
Post Donation Monitoring of Live Liver Donors (5.18)
Transplant Quality Assurance and Process Improvement (QAPI) Policy (6.0)
Adverse Event Reporting and Review Process for Transplant (3.19)
Air and Ground Transportation (1.10)
Attendance and Materials for External Professional Events (1.18)
Billing for Export Organs (1.01)
Conflicts of Interest (1.04)
Correspondence and Direct Contact between Donor Families and Recipients (5.02)
Death Record Reconciliation (4.02)
Designated Requestor Policy (1.11)
Donor and Donor in Spirit Family Support Services Program (5.01)
Dress Code (1.12)
Exempt Status Compensatory Time (1.13)
Hospital Development Activities and Hospital Plans (4.03)
Management of Biohazardous Exposures at Donor Hospitals (1.05)
Medical Record Review, Hospital Classifications, and True Conversion Rate (4.01)
Non-Exempt Status Compensatory Time (1.19)
Non-overnight Travel Meal Reimbursement (1.03)
Notification of Late Arrival or Absence for a Scheduled Shift (Clinical Hourly Staff) (1.15)
Occurrence Reporting System (PSN) (1.08)
OPO Qualified Healthcare Professional Staff (1.16)
Organ and Tissue Donor Education Fund (6.03)
Organ Recovery Invoice Processing (1.02)
Patient Chart Creation and Closure (1.09)
Regulatory Data Submission (1.07)
Retention and Security of UW OTD Patient Records and Hospital Development Records (1.06)
Staff Training and Maintenance of Training Records (1.14)
Third Party Award Nominations (6.04)
Third Party Product Purchases (6.05)
UW OTD Department Credit Card (1.17)
UW OTD Glossary (1)
Volunteer On‐boarding, Off‐boarding, and the Communication Process (6.06)
Guidelines for Responding to Search Warrants, Subpoenas, or Requests for Interviews in Connection with Lawful Government Investigations (100.001)
Interactions with Industry (100.002)
Appointment Cancellation Guideline (101.001)
Chart Completion and Co-Sign (101.003)
Medication Orders and Maintenace (101.004)
Cardiopulmonary Resuscitation (CPR) (101.037)
CPR Card Verification and CPR Card Replacement (101.038)
Debriefing Policy (101.042)
Charts Completion and Co-Sign (101.053)
Closing Telephone Encounters (101.054)
Delegating Work While Absent (101.055)
Downtime – Clinic Operations (101.056)
Off-Site Visits and Procedure Encounter (formerly Off-Site Facility Encounter) (101.057)
Patient Left Without Seeing Provider - Full EpicCare Sites only (101.058)
UW Health Professional Services Compliance Program (103.001)
Compliance Team Standards for Privacy when Transporting PHI (103.002)
OIG Exclusion Checks (103.006)
Capital Asset Purchase and Authorization Policy (105.005)
Credit Card Use Policy (105.006)
Employees Not Issued a Company Cell Phone (105.008)
Installment Payment Policy (105.011)
Moving Expense Reimbursements (105.013)
Non-Tangible Purchase Requisition Guidelines (105.014)
Notary Status Application Process (105.015)
OIG Exclusion Checks (103.006)
Ordering Guidelines For Tangible Items (105.024)
Payment to Non-Resident, Non-U.S. Citizen (105.016)
Purchasing Cards-Petty Funds Policy (105.017)
Requisitioning Policy (105.019)
Supplemental Wages-Paid Out Earned Time (105.020)
UW Health Information Sharing Policy (105.021)
Vendor Reporting (105.022)
CareLink Downtime (HL-020-POL)
Charge Router Change Management (HL-008-POL)
Device Management – LWS Workstation Record (HL-016-POL)
Emergent or Canceled Production Downtime (HL-019-POL)
Environments (HL-013-POL)
Master File Maintenance EAP (HL-001-POL)
Master File Maintenance Willow (HL-006-POL)
Patient Safety Escalation (HL-009-POL)
Print Queue and Device Management Policy (HL-003-POL)
RA SU Management (HL-010-POL)
Restricted Master File Access (HL-017-POL)
Retriggering Charges (HL-015-POL)
RightFax Management (HL-011-POL)
Sharing Health Link-Based Intellectual Property (HL-022-POL)
SuperUser SmartTools Access (HL-021-POL)
Test Patient Creation in Production (HL-005-POL)
UW Health Batch Schedule Request (HL-023-POL)
UW Health IS Business Continuity and Risk Management Policy (AD-POL-006)
Activating Health Link RightFax in the Non-Production Environments Procedure (HL-011-PRO-2)
CareLink Downtime Procedure (HL-020-PRO)
Charge Router Change Management Procedure (HL-001-PRO)
Device Management – LWS Workstation Record Procedure (HL-016-PRO)
Emergent or Canceled Production Downtime Procedure (HL-019-PRO)
Environments Procedure (HL-013-PRO)
Master File Maintenance EAP Procedure (HL-001-PRO)
Master File Maintenance Willow Procedure (HL-006-PRO)
Patient Safety Escalation Procedure (HL-009-PRO)
RA SU Management Procedure (HL-010-PRO)
Restricted Master File Access Procedure (HL-017-PRO)
Retriggering Charges Procedure (HL-015-PRO)
RightFax Management Procedure (HL-011-PRO-1)
Sharing Health Link-Based Intellectual Property Procedure (HL-022-PRO)
SuperUser SmartTools Access Procedure (HL-021-PRO)
Test Patient Creation in Production Procedure (HL-005-PRO)
UW Health Batch Scheduling Request Procedure (HL-023-PRO)
UW Health Batch Scheduling Best Practices -- Text Navigation and Jobs (HL-024-PRO)
UW Health Batch Scheduling Best Practices - Tips and Tricks (HL-025-PRO)
Accounting of Disclosure Policy & Guidelines (107.002)
Coding Standards for Privacy for At-Home Coders (107.014)
Destruction/Disposal of Patient Protected Health Information Media (107.004)
E-Mail of PHI from Health Care Provider to Patient (107.005)
Identity Theft Prevention Program Policy (107.007)
Marketing Use of Protected Health Information (107.009)
Minimum Necessary Use and Disclosure Policy & Guidelines (107.010)
Security & Privacy of Faxed, Printed and Copied Documents (107.013)
Termination of User Access (107.015)
Transcription Standards of Privacy (107.016)
At-Home Coding Policy (108.016)
Attendance and Time Policy (108.017)
Clinic Operations Staff Options During Provider Absence Policy (108.019)
Continuing Medical Education (CME) and Professional Expense (licensing/certification) Guideline for Advanced Practice Providers (108.002)
Employee Grievance Policy (108.025)
Employee Performance Expectations Policy (108.026)
Employement of Relatives & Friends Policy (Nepotism and Consensual Relationships) (108.036)
Exempt Pay Policy (108.027)
Guidelines for Ethical and Professional Behavior (108.008)
Guidelines for Professional Conduct of Physician Faculty in the Clinical Setting (108.009)
Job Sharing (108.011)
Meal and Rest Period Policy (108.034)
Physician Parental Leave of Absence Policy (108.040)
Reinstatement of Employment Policy (108.042)
Secondary Employment Policy (108.044)
Substance Abuse Policy (108.048)
Work Assignment Policy (108.054)
Business Continuity and Risk Management (AD-POL-006)
Change Review and Management (AD-POL-002)
Computer and Server Decommissioning (IN-PRO-009)
Computer Security Incident Response (SE-POL-002)
Consultant Hiring (AD-POL-008)
Credit Card Security (SE-POL-004)
Credit Card Use (AD-POL-004)
Customer Service (AD-POL- 003)
Data Center Access (IN-POL- 001)
Director On Call (AD-POL- 015)
Elevated Privileges (SE-POL-005)
IS Requisitioning (AD-PRO-016)
Monitoring Systems and the Network (IN–POL-010)
Network Equipment Management (IN-POL-004)
New Employee Setup (AD-PRO- 007)
Out of Office Request (AD-POL-010)
Policy and Procedure Development (AD-POL-001)
Problem Review (SE-POL-003)
Project Management (AD-POL- 011)
Software Development Life Cycle Policy for Cardholder Data Environment (SE-POL-007)
System Downtime (AD-POL-005)
System Maintenance and Management (IN-POL-011)
Systems Backup (IN-POL-002)
Systemwide Malware and Antivirus (IN-POL-005)
Telecommuting (AD-POL- 014)
Testing and Troubleshooting (AD-POL-017)
Time Tracking (AD-POL-012)
Vacation and Holiday Selection and Scheduling (AD-POL-013)
Computer Security Incident Response Procedure (SE-PRO-002)
Consultant Hiring Procedure (AD-PRO-008)
Credit Card Use Procedure (AD-PRO-004)
Customer Service Procedure (AD-PRO- 003)
Data Center Access Procedure (IN-POL-001)
Director On Call Procedure (AD-PRO- 015)
Monitoring Systems and the Network Procedure (IN–PRO-010 )
Network Equipment Management Procedure (IN-PRO-004)
New Employee Setup Procedure (AD-PRO-007)
Out of Office Request Procedure (AD-PRO- 010)
Policy and Procedure Development Procedure (AD-PRO-001)
Problem Review Procedure (SE-PRO-003)
Project Management Procedures (AD-PRO-011)
System Downtime Procedure (AD-PRO-005)
System Maintenance and Management Procedure (IN-PRO-011)
Systems Backup Procedure (IN-PRO-002)
Systemwide Malware and Antivirus Procedure (IN-PRO-005)
Time Tracking Procedure (AD-PRO-012)
Unlabeled and Mislabeled Specimens (110.002)
Clinic Receiving Policy (111.001)
Office Supply Ordering Guidelines (111.003)
Return Policy (111.004)
Inspection of Radiation Protection Items (Lead Aprons) (112.002)
Outside Studies Guideline (112.005)
Radiation Monitoring for Pregnant Employees in Radiologic Areas (112.006)
Radiation Protection for Radiology Staff (112.008)
Required Training to Operate Radiology Equipment (112.010)
Vacation and Holiday Time Off Scheduling in Medical Imaging (112.011)
Acknowledgement of Notice of Privacy Practices (113.001)
Assignment of Benefits (AOB) (113.003)
Batching Guidelines (113.004)
Billing for Missed Appointments Policy (113.005)
Changing Appointments After Check-In (113.006)
Charging (113.007)
Company Accounts (113.010)
Confidential Accounts - EpicCare Sites (113.011)
Confidential Accounts - Non-EpicCare Sites (113.012)
Cosmetic & Functional Consultations (113.035)
Encounter Forms (113.014)
GML Drug Screens (113.015)
Hearing Services (113.016)
Multiple Accounts (aka Account Merges) (113.018)
On-Site Payments (aka Cash Management) (113.020)
Prepayment and Time of Services Payment - UWHC Sites (113.021)
Prepayment and Time of Services Payment - UWMF EpicCare Sites (113.022)
Prepayment and Time of Services Payment - UWMF Non-EpicCare Sites (aka Self Payments) (113.023)
Referral Processing (113.026)
Refunding Copays (113.027)
Registration (113.028)
Retail Payments (113.029)
Scanning of Financial Documents (113.030)
Skilled Nursing Facility Accounts (SNF) (113.031)
Split Visits - EpicCare Sites (113.032)
Split Visits - Non-EpicCare Sites (113.033)
Uninsured Discount Policy (113.036)
Unresolved Accounts (113.037)
Wisconsin Well Womens Program (WWWP) (113.038)
Workers Compensation Claims For UWMF Employees (113.039)
Policy on Sanctions for Personnel Breaches of Confidentiality of PHI (114.010)
Controlled Substance Distribution (115.003)
Distribution, Storage, Maintenance and Administration of Clinic Pharmaceuticals (115.004)
MF Clinic Administered Meds with Prior Auth (115.001)
Removing Rubber Tops From Vials (115.007)
Storage of Tamper Resistant Prescription Pads and Paper (115.006)
Record Retention (116.001)
Fire Alarm Testing Policy (117.001)
Fire Protection System Impairment Policy (117.002)
Hot Works (Open Flame/Spark-producing) Permit Policy (117.003)
Madison Surgery Center (MSC) Fire Alarm Testing Policy (117.004)
Madison Surgery Center (MSC) Fire Drill Policy (117.005)
Transformations Surgery Center (TSC) Fire Alarm Testing Policy (117.006)
Transformations Surgery Center (TSC) Fire Drill Policy (117.007)
Chemical Spill Response (118.001)
Hazard Communication Training (118.002)
Hazard Management for Non-routine Tasks (118.003)
Hazardous Material and Waste Management Plan (118.004)
Labeling of Chemicals (118.005)
Liquid Nitrogen Safe Handling (118.006)
Material Safety Data Sheet Management (118.007)
Mercury Spill Policy (118.008)
Pesticide Use Policy (118.009)
Hazardous Drug (HD) Waste Disposal Policy (119.001)
Hazardous Drug (HD) Waste Disposal Policy (120.001)
Storage and Maintenance of Clinic Pharmaceuticals (121.001)
Respiratory Protection Program (122.001)
Ergonomic Guideline for Sonographers at UW Health West Clinic Vascular Surgery (123.001)
Ladder Safety Policy (123.002)
Safety Inspection Policy (123.003)
UW Health Recycling Program (this policy is used by UWHC, UWMF and UWSMPH) (123.005)
Internal Alarming Device Policy (124.001)
Security Management Plan (124.002)
Security Management Plan - 1102 S. Park Street (124.003)
Crisis Debriefing Policy and Procedures (125.001)
Home Visitation Safety (125.002)
In-Custody Patients (125.003)
OSHA Inspection Policy (125.004)
Patient Altercation Response Policy (125.005)
Patient Altercation Response Policy - Behavioral Health and Recovery (125.006)
Patient Altercation Response Policy - Yahara (120.007)
Prohibited Conduct Policy and Procedures (125.008)
Responding to Angry Patients Policy (125.009)
Security Guard Expectations Policy - 1 S. Park Medical Imaging (125.010)
Security Guard Expectations Policy - West Towne (125.012)
Workplace Violence Program (125.013)
Control of Hazardous Energy (Lockout/Tagout) (126.001)
Patient Care Equipment Management Policy (126.002)
Power Outage Policy (126.003)
Reporting of Device-Related Adverse Events and Other Product Problems (126.005)
Water Damage Policy (126.006)
Vehicle Maintenance Policy (127.001)
Access to Enterprise Data for Analytics (1.49)
Administrative (Non-clinical) Policies - Development, Revision, Retiring and Approval (1.10)
Administrator On-Call and Incident Response (1.12)
Alcoholic Beverage Possession and Consumption at UW Health (1.23)
Ambulatory Clinic-Initiated Bereavement/Condolence Cards (1.58)
Computer, Electronic, Communication and Internet Usage Via UW Health Resources (1.29)
Donated Works of Art (1.28)
Donation Policy (1.31)
Employee Gift Policy (1.64)
False Claims Act; Federal Contract Whistleblower Protections (4.50)
Federal and State Funds Policy (1.20)
Flowers (Memorial) Policy (1.65)
Lost, Stolen, or Found Electronic Device Policy (1.61)
Motor Vehicle Policy (1.17)
Non-Solicitation (1.43)
Noncoverage Notifications Required by CMS for Inpatient/Outpatient (1.33)
Parking Policy (1.27)
Patient Identification Photo Capture (1.59)
Patient Safety Evaluation System (1.62)
Policy for Revision of Bylaws, Medical Staff Rules and Regulations (1.24)
Prescriber DEA Registration Numbers (1.63)
Privacy Status and Pseudonym (Alias) Patient Name Requests (1.44)
Professional Services Business Conduct/Compliance Standards (1.60)
Remote Access to Electronic Information Systems (1.01)
Reporting Property Damage and Loss (1.22)
Restricted Areas (1.15)
UW Health Access to Electronic Systems (1.02)
UW Health Authentication and Password (1.53)
UW Health Credit Card Systems and Transactions (1.57)
UW Health Removal of Electronic Systems Access (1.05)
UW Health Scribe Policy (1.55)
UW Health Service Animals/Animal Assisted Activities/Pet Visitation (1.50)
UW Health Smoke Free/ Tobacco Free Workplace (1.41)
UW Health Social Media (1.47)
UW Health Technology Request Policy (1.56)
UW Health Travel and Reimbursement Policy (1.14)
UW Health Wireless Security and Access (1.51)
Visiting Physician Observers (1.45)
Workstation Acceptable Use and Security Management (1.04)
UW Health Nutrition and Sustainability Standards (3.00)
Therapeutic Diet Manual (3.01)
Procurement of Food and Food Supplies (3.03)
Food Catering at UW Health (3.15)
Food Procurement for Patient Therapy Programs (3.11)
Food Safety Practices (3.02)
Stocking and Cleaning of Food in Patient Unit Kitchens and Family Lounges (3.16)
Admission of Foreign Nationals & Prepayment to UW Health (2.20)
Capital Asset Policy (2.30)
Estimated Cost of Medical Service (2.23)
Financial Assistance Policy (2.16)
Financial Screening for Solid Organ Transplant (2.26)
Insurance or Managed Care Prior Authorizations and Notifications (2.21)
Lease Policy (2.34)
Patient Billing and Collections Policy (2.33)
Patient Right to Amend Billing Records (2.25)
Pharmacy Payment and Charging Policy for Take Home Prescriptions (2.18)
Prepayment for Elective Services (2.11)
UW Health Limits for Patient Account Settlements, Discretionary and Non-Discretionary Write-Offs/Adjustments and Patient Refunds (2.31)
Amendment of the Medical Record (6.14)
Centralized Monitoring of Delinquent Medical Records (6.17)
Data Replication Policy (6.47)
Health Information Management Procedure for Verification of Record Entries and Author (6.25)
Health Link Department Master File Policy and Procedure (6.41)
Medical Record Forms and Electronic Content Development Design and Major Revision (6.38)
Medical Record Monitoring for Documentation (6.22)
Medical Record Retention (6.26)
Notification to Health Link and Patient Business Services Department Regarding Deceased Patients (6.46)
Paper Medical Record Control (6.10)
Patient Request to Restrict Use and/or Disclosures of Protected Health Information (PHI) (6.48)
Patient Right to Access (View) Their Protected Health Information (6.13)
Procedures for Approval and Elimination of Existing Subcharts and Shadow Charts to the UW Health Primary Medical Record (6.28)
UW Health Approved Abbreviation List (6.18)
UW Health Legal Medical Record (6.39)
UW Health Medical Record Documentation (6.15)
Caregiver Background Checks (9.03)
Cobra Enhancement Policy (9.87)
Competency Assessments (9.24)
Corrective Action for Non-Compliance with Confidentiality of Protected Health Information (9.11)
Disability Accommodation (9.68)
Drug Free Workplace (9.05)
Employment/ Pre-Employment Reference and Background Check (9.18)
Equal Employment Opportunity and Non-Discrimination (9.27)
Ergonomic Injury Reduction Program (9.63)
Flexing Staff to Volume (Low Census) Policy (9.86)
Health Clearance to Return to Work or Continue to Work (9.22)
Inclement Weather (9.45)
Influenza Vaccination (9.75)
Licensure/Certification/Registration (9.41)
Limits on Hours Worked (9.80)
New Employee Orientation (9.60)
Non-Employee Health Screening (9.21)
Performance Appraisals (9.26)
Position Elimination/Reduction (9.53)
Prospective Employee Health Assessment and Drug Screening (9.20)
Resignation (9.36)
Staff Objections to Participating in Aspects of Patient Care (9.44)
Time Off Policy (9.40)
Training and Competency Verification for RNs Engaged in Clinical Research at UW Health Who are Not Employed by UW Health (9.85)
Tuition Reimbursement (9.39)
UW Health Dress Code and Appearance (9.16)
UW Health Hiring Policy (9.37)
Verification of Work Authorization (9.02)
Workers Compensation (9.17)
Infection Control Precautions During Construction and Renovation (13.16)
Communicable Disease Reporting (13.04)
Electronic Medical Record Audit Policy (4.39)
UW Health Event Reporting (4.22)
Release of Alcohol and Other Drug Abuse Patient Information (4.38)
Caregiver Misconduct Investigations and Reporting (4.47)
Weapons and Controlled Substances (4.26)
Signature Authority Policy (4.01)
Drawing of Blood at Police Request (4.12)
Using and Disclosing (or Releasing) Protected Health Information (4.13)
Release of Protected Health Information for Worker’s Compensation Purpose (4.10)
UW Health Space Utilization Policy (5.17)
Mail Service for UW Health (5.46)
Surplus Property (5.47)
Off-Site Storage of UW Health Property (5.51)
Responding to Requests for Patient Transportation and Parcel Delivery (5.26)
Medical Waste Reduction Policy (5.33)
Environmental Responsibilities on the Inpatient Care Units (5.18)
UW Health Recycling Program (5.24)
Utilization of Radiological Equipment (7.10)
UW Health Evaluation of Capital Clinical Equipment (11.35)
Regulation of Vendor Representatives and the Vendor Liaison Office (11.19)
Bidding and Awarding Construction Contracts (11.31)
Purchasing Authority (11.34)
Handling of Animals for Treatment or Research (12.33)
Product Fire Safety and Infection Control Characteristics (12.39)
Radiation Monitoring for Pregnant Employees in Radiologic Areas (12.12)
Safety Committee Authority and Function (12.26)
UW Health Environment of Care Safety Program Policy (12.64)
Key Control (12.57)
SMDA Medical Device Tracking (12.47)
Product Recalls and Safety Alerts (12.46)
Interim Life Safety Program (12.45)
Inspection of Radiation Protection Items (12.13)
Electrical Safety (12.63)
Compassionate Use of an Investigational Agent or Use of an Investigational Agent from a Second Institution (4.27)
Discharge Against Medical Advice/Elopement from Hospital (4.19)
Disclosure of Unanticipated Outcomes to Patients/Family (4.45)
Informed Consent (4.17)
Patient Rights and Responsibilities (4.34)
Videotape Recording & Patient Photographs (4.15)
Provider-Patient Email (6.32)
Aggressive or Disruptive Patient Behavior in the Emergency Department (10.16)
Administration of Medications (8.17)
Adverse Drug Event Documentation (8.20)
Care of the Pregnant Patient NON-TRAUMA (8.61)
Guidelines for Decisions to Limit Life-Sustaining Medical Treatment (8.25)
Guidelines for Treating Patients When They Refuse Medical Treatment (8.24)
High Alert Medication Administration (8.33)
DOC Patient (Inmate) Clinic Visits: Scheduling, Transport Care & Security (7.52)
Medication, Medication Container and Solution Labeling (7.80)
Professional Boundaries and Therapeutic Relationships within UW Health (7.55)
Certification Cardiopulmonary Resuscitation & Other Life Saving Interventions (9.35)
Administration of Depo-Provera in Clinics (12.61)
Administration of Lupron (Leuprolide) in Clinics (12.44)
Ambulatory Tuberculin Bacillus (TB) Skin Testing Procedures (12.50)
Balloon Catheter Urethral Dilation - Urology Clinic (12.65)
Bladder Instillation of DiMethyl Sulfoxide (DMSO) - Urology Clinic (12.19)
Circumcision of the Newborn, Assisting With Procedure - Pediatric Primary Care Clinics (12.04)
Extracorporeal Shock Wave Lithotripsy (ESWL) on Patients with an Implanted Pacemaker and/or Implantable Cardioverter Defibrillator (ICD) Device – Urology Clinic (12.57)
Fetal Heart Tones - OB/GYN, Midwives, Women's Health Center-East/West (12.09)
Initiating a Peripheral Intravenous (PIV) Line and PIV Therapy in UWHC Clinics - Pediatric and Adult (12.02)
Non-Stress Test (NST) - OB/GYN and Midwives-East/West (12.07)
Operation for Electrical or Thermal Cautery - Mohs Surgery Clinic East and West (12.31)
Papoose Board - Pediatric Clinics (12.06)
Policy for Chaperones for Sensitive Physical Exams (12.05)
Prostate Balloon Dilation - Urology Procedure Center (UPC) (12.18)
Prostate Biopsy - Urology Clinic (12.52)
Radiation Safety in the Lithotripsy Suite - Urology Clinic (12.56)
Review of Diagnostic Test Results and Notification to Patients in the UW Health Carbone Cancer Clinics (12.14)
Review of Test Results and Notification to Patients - Transplant Program (12.70)
Telephone Management of Animal Bites in Clinics (12.08)
Telephone Standards in the UW Health Carbone Cancer Clinics (12.13)
Thiotepa or Mitromycin Bladder Installation - Urology Clinic (12.64)
Ultrasound Post-Void Residual (US PVR) Bladder Scan - Adult Urology Clinic (12.53)
Urodynamic Testing (Children) - Pediatrics Specialties Clinic (12.39)
Uroflow Procedure in Clinics (12.55)
Urology Bladder Instillation – Bacillus Calmette Guerin (BCG) (12.75)
Vasectomy - Urology Clinic (12.45)
Video and Non-Video Urodynamic Testing (Adult) - Urology Clinic (12.63)
Medical Emergency Response - Digestive Health Center (DHC) (4.09)
Assessment and Reassessment of Patients and Documentation in Clinics (8.02)
Review of Diagnostic Test Results and Notification to Patients (8.01)
Telehealth Standards in Ambulatory Clinics (8.20)
Ambulatory Nursing Staff Roles and Responsibilities (2.02)
Ambulatory Staffing Planning or Responding to Changes in Staffing Model (2.03)
Orientation of Personnel to Ambulatory Clinics (2.04)
Acceptance Policy for Specimen Identification (1502.5.06)
Outpatients Needing Lab Service When the Outpatient Lab is Closed - CSC Only (1507.BD.2.4)
Skin Puncture Blood Collection (1507.P010)
Specimen Rejection (1502.5.07)
UWHC Releasing Conventions (1506.HL1.16)
Venipuncture Technique (1507.P009)
Nutrition Assessment and Reassessment of Outpatients in Clinic (5.2)
Guidelines for Patient Instruction Drug-Nutrient Interactions (3.07)
Nutritional Care and Monitoring for Inpatients at University Hospital and The American Center (3.3)
Parental Nutrition Assessment, Ordering and Monitoring (3.6)
Formula and Donor Human Milk Recall Policy (4.9)
Infant Formulary (4.1)
Nutrition Screening in NICU (4.8)
Nutritional Care and Monitoring for Inpatients at American Family Children’s Hospital (4.5)
Critical Care Transport RN and RT Assistance in the Emergency Department (ED) (1.39)
Decontamination-Biohazardous Materials or Radiation (9.0)
Deep Sedation in the ED (33.3)
ED - Protocols (11.0)
Educational and Travel Opportunities (31.3)
Emergency Department Clinical Decision Unit (48.5)
Emergency Department Hand Off Communication Guidelines (7.0)
Emergency Department Technician Documentation (1.0)
Emergency Department-Lending policy for equipment (2.0)
EMS Wast of Controlled Substances in the ED (38.2)
Fall Prevention for Adult ED Patients (5.0)
Hyaluronidase Administration and Subcutaneous Hydration (12.0)
Intraosseous Access and Care Using the EZ IO (3.0)
J-Tip Use in ED (50.2)
Ketamine: Low Dose IV Ketamine with Pain Management for Adult Patients in the ED (31.1)
Maintaining a Safe and Secure Environment (40.5)
Medications in the Emergency Department: Managing STAT and Urgent (8.43)
Patient and Family Centered Care (8.0)
Patients Who Leave Before Disposition (4.0)
Procedures in the Emergency Department (35.3)
Provider Delivered Inhaled Nitrous Oxide in the Pediatric Emergency Department (ED) (44.4)
Safe Discharge from the Emergency Department (6.0)
Screening of Emergency Department Patients (10.0)
The Management or Exchange of a Supraglottic Airway Device (31.2)
Ultrasound Guided Peripheral IV Access (14.0)
Vital Signs in the Emergency Department (31.4)
Implantable Cardioverter Defibrillator ICD Clinic Check, Routine (HVC)
Management of Pacemaker or Implantable Cardioverter Defibrillator (ICD) Devices in a Procedural Setting (HVC)
Pacemaker Clinic, Routine Visits (HVC)
Pacemaker Transtelephonic Check (HVC)
Remote Loop Recorder (HVC)
Remote Transmission of a Pacemaker, Implantable Cardioverter Defibrillator ICD (HVC)
Medical Records for Dialysis Services provided to Middleton’s Memorial Veterans Administration Hospital (VAH) (1.3)
Blood product procedures and administration during Hemodialysis (3.6)
Administration of Routine Medications given with Dialysis (3.3)
Hemodialysis treatment using the Gambro Phoenix® Machine (3.1)
Blood Specimen Collection Performed in Hemodialysis (3.4)
Hemodialysis treatment using the Fresenius 2008 Series (K & T) Machines (3.10)
Phoenix™ Dialysate Meter Readings, Quality Assurance (QA), Calibration, Cleaning and Disinfection (2.9)
Maintenance of the DiaSafe Plus™ Filter on the Fresenius 2008K and 2008T Dialysis Machine (2.8)
Routine Cleaning, Disinfection, Operation and Maintenance of the Gambro WRO 300 Portable RO (2.7)
Routine Cleaning, Disinfect, and Maintenance of the Hemodialysis Machine (2.6)
Disinfection of the RO, distribution loop, storage tank and Hemodialysis machine inlet water line (2.4)
Corrective Action Plan in the event of Positive Water Cultures/Endotoxins (2.3)
Reverse Osmosis (RO) In-center Loop Contingency Plan (2.2)
Water Analysis Testing and Sampling procedure for product water Colony Count and Endotoxin levels (2.1)
Monitoring of the Reverse Osmosis (RO) Water Systems (2.0)
Hemodialysis patient room cleaning and disinfection routines (5.1)
Roles and Responsibilities for Insertion and Removal of Central Venous Catheters in the Hemodialysis Unit (6.0)
Insertion and Removal of Hemodialysis Access Needles (6.2)
Hepatitis B and C Screening and transmission prevention in Hemodialysis (5.0)
Patient assessment and monitoring before, during and immediately after hemodialysis (3.9)
Management of Hemodialysis treatment related complications (3.8)
Scope of Services delivered by UWHC Inpatient Hemodialysis Department (1.0)
Visiting Policy for Patients on Hemodialysis (1.2)
Informed Consent for Dialysis and Related Procedures (1.1)
Emergency Disconnect from the Gambro Phoenix® or Fresenius 2008K® Machine (7.0)
AFCH Safe Sleep for Inpatients (13.25)
Application of Physical Restraint (Adult & Pediatric) (13.23)
Basic Care - Inpatient Pediatrics (Birth-18 years of age) (Pediatric) (13.16P)
Basic Care Standards (Inpatient Adult) (13.12)
Documentation in the Inpatient's Clinical Record (13.14)
Fall Prevention for Inpatients (Adult & Pediatric) (13.15-AP)
Hearing Screen of Newborns (13.26)
Hypoglycemia, Care of the Hospitalized Patient (Adult and Pediatric) (13.24 AP)
Skin-to-skin Holding (Kangaroo Care) of the Neonate (Pediatric) (13.27-P)
Alaris System (1.24)
Ankle-Brachial Pressure Index Measurement (1.46)
Arterial Catheter/Insertion, Maintenance, Blood Drawing and Discontinuation (Adult) (1.11A)
Arterial Catheter/Insertion, Maintenance, Blood Drawing and Discontinuation (Pediatric) (1.11P)
Care of Hemodialysis/Apheresis Catheters (Adult and Pediatric) (1.28AP)
Care of Patient Receiving a Continuous Peripheral Nerve Block (Perineural) Infusion (1.41)
Care of Umbilical Catheters (Arterial and Venous) (Pediatric) (1.48P)
Care of Vortex® Vascular Access Device when Used for Apheresis (Adult & Pediatric) (1.57)
Caring for Adult & Pediatric Patients Requiring Cardiac Monitoring (1.31)
Central Vascular Access Device Use, Maintenance and Removal (Adult and Pediatric) (1.56)
Central Venous Pressure (CVP) Monitoring (Adult) (1.45)
Central Venous Pressure (CVP) Monitoring (Pediatric) (1.45)
Continuous Peripheral Intravenous Therapy (Adult and Pediatric) (1.23AP)
Elective Direct Current (DC) Cardioversion (Adult and Pediatric) (1.38AP)
Hyaluronidase Administration and Subcutaneous Hydration for Pediatric Patients (Pediatric) (1.52-P)
Insertion of Peripherally Inserted Central Venous Catheters and Midline Catheters for Venous Access Team (Adult and Pediatric) (1.51 AP)
Insertion, Assessment and Removal of the Intraosseous Access EZ® IO (1.44)
Intra-Abdominal Pressure Monitoring (1.43)
Intra-Aortic Balloon Pump (IABP) Set-Up, Insertion, Operation and Maintenance (Adult) (1.34A)
Intravascular Cooling Catheter System - Thermogard XP (Adult & Pediatric) (1.42AP)
Invasive and Non-invasive Hemodynamic Monitoring (Adult) (1.14)
Management of Indwelling Pericardial Catheter with Drainage Bag (Adult & Pediatric) (1.47AP)
Mechanical Circulatory Devices (MCD) (Adult Inpatient) (1.40)
Midline Intravenous Peripheral Catheters: Use, Maintenance and Removal (Adult) (1.55)
Neonatal Blood Exchange Transfusion (Pediatric) (1.54P)
Photopheresis (Adult) (1.05A)
Radial Compression Device (1.50)
Reconstitution/Administration of Factor VIII or Factor IX Concentrate for Patients with Hemophilia A or B or Von Willebrand Disease (Adult and Pediatric) (1.10AP)
Red Blood Cell Exchange (Adult and Pediatric) (1.04AP)
Sequential Compression Device For Legs and/or Feet (Adult) (1.29A)
Temporary Pacing: Transvenous, Transcutaneous, Epicardial, and Semi-Permanent (Adult) (1.37A)
Therapeutic Leukopheresis (Adult) (1.02A)
Therapeutic Phlebotomy (1.07)
Therapeutic Plasma Exchange (Adult and Pediatric) (1.01AP)
Ultrasound Guided Peripheral IV Placement (Adult & Pediatric) (1.53 AP)
Use of Near-Infrared Spectroscopy (Cerebral and Somatic Oximetry) in the Pediatric and Neonatal ICU (Pediatric) (1.49-P)
Use of the Implanted Intraperitoneal (IP) System (1.30)
Arterial Blood Specimen Drawing via Direct Radial Artery Puncture (11.11)
Assisting with Suprapubic Aspiration (Pediatric) (11.30P)
Capillary Blood Specimen Collection (Pediatric) (11.12P)
Collection of Sputum Specimen (Adult & Pediatric) (11.25 AP)
Collection of Stool Specimens for Laboratory Examination (Including Ova and Parasites)(Adult & Pediatric) (11.14-AP)
Lumbar Puncture (Adult & Pediatric) (11.17-AP)
Nova Stat Strip® Blood Glucose Meter (11.26)
Percutaneous Paracentesis (Adult & Pediatric) (11.10-AP)
Thoracentesis or Chest Aspiration (Adult) (11.22-A)
Care, Use, Maintenance and Discontinuation of Enteral Tubes (Adult & Pediatric) (2.20)
Gastrostomy Care (Pediatric) (2.17P)
Gastrostomy Tube Care and Replacement of Surgically and Endoscopically Placed (PEG) Gastrostomy Tubes (Adult) (2.17A)
Nasal Bridles: Use, Maintenance and Removal (Adult and Pediatric) (2.24AP)
Off Hours Metabolic Formula Preparation for Pediatric Patients with Inborn Errors of Metabolism (Pediatric) (2.26)
Ostomy Care (Adult) (2.18A)
Ostomy Care (Pediatric) (2.18P)
Placement of Small Bowel Feeding Tube Using Cortrak Enteral Access System (Adult & Pediatric) (2.25)
Unclogging Enteral Feeding Tubes (Adult and Pediatric) (2.22AP)
Use of Fecal Management System (2.23)
Connecting and Disconnecting from Peritoneal Dialysis Cyclers (Adult) (3.32A)
Continuous Bladder Irrigation (CBI) - Adult (3.30)
Continuous Renal Replacement Therapy (CRRT) Using the NxStage System One Machine (Adult & Pediatric) (3.11AP)
Infant Peritoneal Dialysis Setup Using the GESCO Dialy-Nate Set (Pediatric) (3.17-P)
Insertion, Maintenance and Removal of an Indwelling Urinary Catheter (IUC) (Adult & Pediatric) (3.31)
Peritoneal Dialysis Fresenius Stay-Safe CAPD Exchange (Adult) (3.22A)
Replacement and Care of a Suprapubic Catheter (3.18A)
Sterile Intermittent Straight Catheterization for Bladder Decompression (3.15AP)
Application of Heat Using a Portable Heat Therapy Unit or Instant Hot Pack (4.18)
Care of Acute Postoperative Surgical Incisions Approximated with Sutures or Staples (Adult) (4.25A)
Changing Sterile and Clean Wound Dressings (Adult & Pediatric) (4.23-AP)
Eye Irrigation for Removal of Foreign Material or Chemical Substance (4.12)
Negative Pressure Wound Therapy Vacuum Assisted Closure (VAC) Ulta Dressing Maintenance and VAC Veraflo Instillation Therapy (4.22)
Neonatal Thermoregulation (Pediatric) (4.20-P)
Neonatal Whole Body Cooling (Pediatric) (4.24-P)
Patient Monitoring During Burn/Wound Care (4.16)
Access to Intrathecal Reservoirs & Administration of Medications Including Chemotherapeutic Agents (Adult & Pediatric) (10.14-AP)
Administration of Echocardiography Contrast Agents (10.24)
Chemotherapy Competence for Nurses (Adult & Pediatric) (10.28AP)
Continuous Subcutaneous Opioid Infusion (10.12)
Inpatient Tuberculin Bacillus (TB) Skin Testing Procedure (10.11)
IV Epoprostenol (Veletri) Administration (Adult and Pediatric) (10.21AP)
Medication Administration Using Barcode Scanning Technology (Adult and Pediatric) (10.19)
Parenteral (Intravenous or Subcutaneous) Lidocaine for Neuropathic Pain (Adult & Pediatric) (10.18AP)
Treprostinil (Remodulin) Administration (10.27)
Admission to Inpatient Psychiatry from Jail (8.34)
Car Seat Angle Tolerance Screening (Pediatric) (8.38-P)
Cleaning of the Burn Hydrotherapy Room (8.11)
Gait Belt and Patient Mobilization Procedures (8.25)
Human Milk Collection and Storage (Adult & Pediatric) (8.28P)
Hypo/Hyperthermia Thermal Blankets for Adult and Pediatric Patients (Excluding Neonates)(Adult and Pediatric) (8.12AP)
Patient Warming System With Forced Air Overbody and Underbody Blankets (such as Bair Hugger Patient Warming System) (8.19)
Peripheral Nerve Stimulation (Adult & Pediatric) (8.36-AP)
Postmortem Care (Adult and Pediatric) (8.14)
Privileges for Inpatient Psychiatry (Adult) (8.32A)
Repair or Replacement of Essential Equipment in Case of Breakdown (Adult & Pediatric) (8.39AP)
Safety Considerations for the Admission Procedure on Inpatient Psychiatry (8.31A)
Therapeutic Support Surfaces and Frames (Specialty Beds)(Adult & Pediatric) (8.17AP)
Use of Intravenous and Rapid Infusor Fluid Warmers (Adult & Pediatric) (8.26-AP)
Visitor Policy for Inpatient Psychiatry (8.33)
Warming Cabinets/Devices for Warming Fluids and Linen (Adult and Pediatric) (8.35)
Cervical Traction (5.10)
Lower Extremity Compression Therapy (Adult) (5.12-A)
Care of the Patient with a Lumbar Drain (6.16)
6.12AP External Ventricular Drainage System (Adult & Pediatric) (6.12-AP)
Intracranial Pressure Monitoring Using the Codman Intraparenchymal Sensor (Adult and Pediatric) (6.15)
Maintenance and Care of Neuroendovascular Femoral Arterial Sheaths (6.18)
Seizure, Care of the Hospitalized Patient with or at Risk for (Adult & Pediatric) (6.10AP)
Care of the Infant Requiring Phototherapy for the Management of Hyperbilirubinemia (Jaundice) (Pediatric) (15.13P)
Autotransfusion Using the Atrium Chest Tube (7.20)
Care of the Intubated Patient (Adult) (7.11-A)
Care of the Intubated Patient (Pediatric & Neonatal) (7.11-P)
Care of the Patient with a Tracheostomy Tube (Adult) (7.19-A)
Care of the Patient with a Tracheostomy Tube (Pediatric) (7.19-P)
Closed Chest Tube Drainage System (Adult and Pediatric) (7.12AP)
High Flow Nasal Cannula for Pediatric Patients (7.21P)
Incentive Spirometry (7.10)
Tracheal Suctioning of the Patient Without an Artificial Airway (7.17)
Assignment of Patient Care on Inpatient Units (Adult and Pediatric) (14.39)
Communication About Patient Death or Imminent Death - Butterfly Sign (14.15)
Constant Observation (Adult and Pediatric) (14.40)
Discharge of the Inpatient (Adult & Pediatric) (14.12)
Escort of Pediatric Inpatients to Tests and Procedures (Pediatric) (14.32P)
Infection Control Practices in the Burn Center (14.14)
Inpatient Psychiatry Seclusion Suite (14.34-A)
Intentional Rounding (Adults and Pediatric) (14.35)
NICU Visitation and Infection Control (Pediatric) (14.36P)
Nurse Call System (Adult & Pediatric) (14.41 AP)
Nurse-to-Nurse Change of Shift Hand-Off – Inpatient (Adult & Pediatric) (14.33AP)
Preparing a Continuity of Care Referral for an Inpatient Discharge (Adult & Pediatric) (14.19AP)
Transfer of the Patient (Adult & Pediatric) (14.17AP)
AcuDose Cabinet Hardware Malfunctions and Downtime Policy (14.1)
Acudose Return Bin Audit (14.5)
AcuDose Support (14.6)
AcuDose-Rx (14.4)
Anticoagulation Monitoring by UW Anticoagulation Clinic Pharmacists (2.3)
Checking for Expired Medications at UWHC Ambulatory Pharmacies (2.12)
Validation and Screening of Patient Allergies (2.2)
Barcode Packaging of Medications using the Robot and Bulk Packager (4.2)
Medication Delivery Via Pneumatic Tube System (4.1)
Bleeding Disorder Program Procedures (15.9)
Critical Care Case Pack Systems Supplied to Med Flight and CHETA (15.6)
Medication Use in Outpatient Care Areas (15.2)
Virtual Colonoscopy Prep Kit (15.7)
Wisconsin Dialysis Inc. (WDI) Operating Procedures (15.5)
Cactus Smart Sink Operations (7.17)
Controlled Drug Distribution and Management for the UW Athletic Department (7.13)
Controlled Substance Discrepancy Reporting (7.4)
Controlled Substances - Ambulatory Procedure Center (7.12)
Controlled Substances Recordkeeping (7.5)
Disposal of Controlled Substances (7.9)
Documentation of Controlled Substance Use in UWHC Clinics (7.6)
Evaluation of Controlled Substance Prescriptions within UW Health Community Pharmacies (7.18)
Narcotic Control in Sterile Products Area (7.15)
NarcStation Operations (7.1)
Ordering Schedule II Controlled Substances From a Manufacturer or Wholesaler (7.2)
Physician DEA Numbers (7.3)
Power of Attorney for DEA Order Forms (7.8)
Schedule II Controlled Substance Procedures for Community Pharmacies (7.14)
Single Patient Controlled Substances Case Packs for the Operating Room (7.7)
Automatic Stop Dates (3.4)
Blue Cart and Stat Pages for Pharmacists (3.9)
Inpatient Hand Off Communications (3.20)
Maintenance & Cleaning – Carts and Inpatient Team Support Areas (3.30)
Medication Education (3.18)
Patients Own Medications Storage and Use (3.5)
Pharmacist Clinical Monitoring (3.3)
Pharmacist Discharge Reconciliation and Order Modification (3.1)
Validated Pharmacy Technician (VPT) Cart Check Program (3.33)
Poison Brochure Mailouts (11.1)
Public Talks - Poison Prevention and Education Center (11.3)
Admitting a Drug to the Formulary (13.21)
Adverse Drug Reaction Evaluation and Reporting System (13.8)
Dietary Supplements (13.14)
Drug Formulary (13.6)
Drug Product Selection and Supply Subcommittee (13.22)
Medication Floor/Area Stock (13.13)
Patient Education Committee - Patient Drug Monographs (13.15)
Safety Strategies for Handling Sound-alike and Look-alike Meds (13.20)
General Statement on Pharmaceutical Compounding (8.1)
Mngt. of Emergency and Non-Emergent Kits, Boxes, and Trays (8.7)
Pharmacist working in Nuc Pharmacy without UWHC Authorized User Status (17.2)
Preparation and Dispensing of Sterile Radiopharmaceuticals (17.1)
Malignant Hyperthermia Box for Operating Room Use (16.1)
ADT and Medication Order Processing for Hospice Patients (19.1)
Pharmaceutical Research Center (PRC) Fee Restructure (10.3)
PRC Distribution of Research Drugs/Supplies (10.4)
PRC External Sponsor/Agency Audits (10.8)
PRC Goals and Objectives (10.1)
PRC Inventory Management (10.5)
PRC Protocol Closure (10.6)
PRC Protocol Initiation (10.2)
PRC Quality Assurance/Statistics (10.7)
PRC Secondary Protocols (10.9)
PRC Training and Competency (10.10)
Contracting and Purchasing Program Enrollment Policy (9.9)
Drug Product Defect Reporting (9.6)
Drugs Sold to External Entities (9.12)
Emergency Drug Procurement (9.4)
Generic Alternative Selection Procedure (9.5)
Medication Recalls (9.2)
Non-Formulary Medications for Inpatients Use (9.1)
Outsourcing of Compounded Drug Products (9.7)
Product Shortage Notification and Therapeutic Alternative (9.3)
Retail Pharmacy Annual Inventory Validation (9.10)
Vaccine for Children (VFC) Ordering Procedure (9.11)
Sterile Product Preparation (6.0)
CoaguChek® XS Pro INR (1595.P42)
Fecal Occult (Guaiac) Hemoccult® (1595.P041)
Hemochron Signature Elite Activated Clotting Time Testing (1595.P007 )
Urine Specific Gravity by Refractometer (1595.P038 )
Urinalysis Testing with Labstix Reagent Strips, Hemacombistix Reagent Strips or Multistix Reagent Strips (1595.P039 )
Patient Identification - Radiology (1.01)
Radiology Disaster Plan (1.07)
Utilization of Radiological Equipment (1.02)
Manual Resuscitation (1.55)
Aerosolized Medication Treatment Via Small Volume Nebulizer (2.27)
Continuous Nebulized Aerosols (2.33)
Direct Instillation of Medications/Lubrication Agents via Artificial Airway (2.30)
Inhaled Pentamidine (2.32)
Inhaler Medication Treatment (2.25)
Placement, Care, & Removal of Endotracheal Tubes (3.43)
Speaking Valves (3.46)
Suctioning (3.42)
Tracheostomy Tube Change and Weaning (3.45)
Abdominal Couch Assist & Bicostal (Costophrenic) Cough Assist (3.13)
Cough Assist Machine (3.16)
Flutter & Acapella (3.15)
High Frequency Chest Compression Vest Treatment (HFCC) (3.12)
Intrapulmonary Percussive Ventilation (IPV) (3.14)
Positive Expiratory Pressure (PEP) (3.11)
Postural Drainage, Percussion & Vibration (P&PD) (3.10)
Respiratory Therapy Protocols (1.53)
Breathhold with Mechanically Ventilated Patients in CT (2.06)
Guidelines for Administration of Invasive & Noninvasive Respiratory Support in Nuclear Medicine Procedures (2.09)
High Frequency Oscillatory Ventilation (HFOV) (2.03)
Mechanical Ventilation Adult and Pediatric (2.02)
Non-Invasive Assisted Ventilation (2.12)
Recruitment Maneuver (2.11)
Transportation Of Patients Supported By Mechanical Ventilator (MV) (2.05)
Aerosol and/or Humidity Therapy (2.21)
High Flow Nasal Cannula (2.22)
Oxygen Therapy (2.18)
Transport Oxygen (2.20)
Apnea Test To Assess Brainstem Function (3.27)
Arterial Puncture (3.26)
Capnography (3.22)
Nocturnal Oximetry/Capnography Studies (3.21)
PEEP of Maximum Compliance/O2Saturation "Best PEEP Study" (3.33)
Pulse Oximetry Check & Continuous Monitoring (Includes Ambulating SPO2) (3.20)
Spirometry Including Peak Expiratory Flow Rate (3.28)
Spontaneous Ventilatory Parameters (3.24)
Sputum Induction (3.30)
Blind Bronchoalveolar Lavage or Non-Bronchoscopic BAL (3.55)
Bronchoscopy (3.57)
Heliox (3.52)
Inhaled Epoprostenol (3.51)
Inspiratory Resistive Exercises (3.54)
Nitric Oxide (3.53)
Surfactant (3.56)
Constant Positive Airway Pressure (CPAP) - Continuous and Intermittent (3.03)
Cough and Deep Breathing (3.01)
Intermittent Positive Pressure Breathing (IPPB) (3.02)
Case Scheduling Outpatient Surgery Center - Operating Room (1.42)
Dress Code in the Department of Surgical Services (1.06)
Incapacitated Surgical Team member - Safe Patient Coverage (1.61)
Indirect Surgical Supervision in the Intraoperative Areas (1.63)
OR Controlled Substances - Holidays, Inpatient OR, AFCH OR and TAC (1.03)
OR Controlled Substances - Weekdays, Inpatient OR, AFCH, TAC and OSC (1.04)
Parental Presence in AFCH PACU (1.62)
Parents/Support Person Present with Child at Induction of Anesthesia (1.15)
Pharmacy Services: Outpatient Surgery Center (PACU/Amb Care) (1.39)
Prisoners, Care of in the Inpatient OR (1.40)
Scheduling, Preparing, and Organizing Patient for Transplantations, i.e. Liver, Heart, Lung, Kidney-Pancreas, and Kidney (1.09)
VA Patients in the UWHC Operating Room - Identifying and Charging (1.35)
Visitors in Surgical Services/OR: Students, Observers, Media Access (1.24)
Waiting Areas (1.33)
Anesthesia Daily/Monthly OR Cleaning, Stocking and Assisting for All Procedures, Including Satellite Area Procedures in Perioperative Areas (3.01)
Admission of Patients to Surgical Services and Requirements for Initiation of Surgical Procedures (2.01)
Blood and Blood Components - OR (2.04)
Cardiac Arrest Protocol (2.05)
Closed Autologous Blood Recovery System (2.07)
Documentation for the Care of the Patient in the Operating Room (2.10)
Electrosurgical Safety (2.11)
Hysteroscopy - Management of Uterine Distention Fluid (2.53)
Immediate Use Steam Sterilization (IUSS) in UW Health Operating Rooms (2.31)
Latex Hypersensitivity Protocol (2.16)
Management of Malignant Hyperthermia Susceptible Patients and a MH Crisis (2.18)
Operative Triage of the Trauma Patient (2.29)
Outpatient Surgery Center Post-Operative Patient Call Back (2.02)
Outpatient Surgery Center Pre-Operative Requirements (2.03)
Perioperative Preparation of the Surgical Site: Hair Removal and Surgical Skin Preparation (2.21)
Skin Tissue Banking - Autologous Bone Flap Storage - Cardiac and Eye Tissue Storage (2.23)
Surgical Counts (2.54)
Transfer of Stereotaxic Biopsy Patients from the Inpatient PACU to CT Scan (2.38)
Transportation of Patients to the Inpatient OR (2.28)
Use of PACU Discharge Scoring Criteria – Adult (2.36A)
Use of PACU Discharge Scoring Criteria – Pediatric (2.36P)
Criteria for Evaluating and Purchasing Aseptic Barrier Material for Surgical Gowns and Drapes (4.01)
Medical Gas Tank Supply for Operating Room and Anesthesia (4.03)
Operating Room Pan Inventory (4.08)
Pneumatic Tourniquet, Use of (4.09)
High Level Disinfection Guidelines 2% Glutaraldehyde for Semi-Critical Items (5.03)
Fire Response Guidelines - Surgical Services (6.01)
Intraoperative Laser Safety Precautions and Endotracheal Fire Control (6.05)
Intraoperative MRI Safety (6.12)
Operating Room Blood Refrigerator Monitoring (6.07)
Archived Serum and Plasma Storage (2.13)
Bedside Liver Biopsy (2.09)
Cleaning the UW OTD Laboratory and Lab Office (3.05)
Deceased Donor Organ Imports (3.03)
Disposal of Regulated Medical Waste (3.07)
Equipment Temperature Tracking (3.06)
First Person Authorization Determination and Conflict Resolution (2.15)
Implementation of OPTN Liver Allocation Policies (2.16)
Increased Risk for Disease Transmission Identification and Reporting (2.04)
Inspection of Sterile Supplies and Equipment (3.10)
Kidney Machine Perfusion and Cold Storage (3.08)
Legal Next of Kin Consent for Donation (2.06)
Local Recovery Surgeon Verification (3.01)
Medical Examiner or Coroner Consent for Donation and District Attorney Notification (2.05)
Moment of Silence (3.12)
Organ Allocation for Local Donors and Directed Donation (2.12)
Organ Donation after Circulatory Death (DCD) (2.07)
Organ Recovery (3.11)
Packaging and Labeling of Organ Donor Vessels (3.09)
Packaging, Labeling, and Storage of Organs and Tissue Typing Materials (3.04)
Patient Assessment and Management for Organ Donation (2.03)
Potential Disease Transmission Post‐Transplant (2.14)
Recovery Team Professional Code of Conduct (3.02)
Reporting Culture Results and Other Post-Recovery Results (2.08)
Requests for Additional Tissue and/or Blood Samples (2.11)
Response and Tracking of Referrals of Potential Organ, Tissue and Eye Donors (2.01)
Verification of the Determination of Brain Death (2.02)
Visiting Recovery Surgeon Credential Verification (ACIN) (2.10)
Code Blue Policy Generations (101.020)
Code Blue Policy Transformations Clinic (101.029)
Assisting with EKG's (102.001)
Bubble Study (102.002)
Blood Draws From Central Venous Catheters (102.003)
Line Maintenance for Central Venous Catheters - PICC and Tunneled Lines (102.005)
Medication Administration Via Venous Access Ports (102.006)
PICC Removal (102.007)
Site Care and Dressing Change for Central Venous Catheters - PICC and Tunneled Lines (102.008)
Venous Access Ports - Accessing and De-Accessing (102.009)
Administering a Fleet Enema (102.012)
Eye Irrigation (102.013)
Female Catheterization (102.010)
Male Catheterization (102.011)
Nasopharyngeal (NP Swab) Collection (102.014)
Nasopharyngeal Wash Specimen Collection (102.015)
Collecting A Throat Culture (102.016)
Guidelines for Chaperones for Sensitive Exams (102.019)
Leaving Against Medical Advice (AMA) (102.024)
Policy Format and Review - Clinical Policies and Procedures (102.027)
Prescription Renewal Requests (102.028)
Telecommunications Confidentiality (102.029)
Dressing Instruction for Patients Post Dermatology Procedure (102.030)
Dressing Change/Wound Care – Dermatology Clinic (102.031)
Hyfrecator (102.032)
Paring of Warts (102.034)
Patch Testing (102.035)
Punch Biopsy (Sterile or Non-sterile) (102.036)
Injection of Local Anesthesia (102.033)
Shave Biopsy (With or Without EDC - Electros Desiccation and Curettage) (102.037)
Surgical Excision (102.038)
Wart Removal: Dermatology Clinic (With or Without EDC -Electro Desiccation and Curettage) (102.039)
24 Hour pH Monitor Scheduling and Patient Instruction (102.040)
Endoscopic Retrograde Cholangiopancreatography - ERCP (102.041)
Esophageal Manometry Scheduling and Patient Instruction (102.042)
Remicade Infusion (102.043)
Measuring Head Circumference in Infants (102.046)
Measuring Length of Infants (102.047)
Measuring Weight in Infants (102.048)
Papoose Board Restraint (Pediatrics) (102.049)
TB Skin Test Placement/Reading Policy (102.061)
Initiating a Peripheral Intravenous (PIV) Line and PIV Therapy (102.051)
IV Solutions: Primary & Secondary Solutions for Adult & Pediatric Patients (102.052)
Line Maintenance and Monitoring of Peripheral Intravenous Lines (102.053)
Medication Administration via a Peripheral Intravenous (PIV) Line (Adult & Pediatric) (102.054)
Removing a Peripheral Intravenous Access Device (102.055)
Medication Administration From a Vial (102.062)
Medication Administration From an Ampule (102.056)
Post Administration of Medications “Waiting Times” (102.059)
Administering Buccal, Sublingual and Translingual Medications (102.063)
Administering Inhaled Medications (102.064)
Administering Intramuscular Injection (IM) (102.066)
Administering Nasal Medications (102.067)
Administering Oral Medications (102.069)
Administering Otic Medications (102.070)
Administering Rectal Medications (102.071)
Administering Subcutaneous Injection (102.072)
Administering Topical Medications (102.073)
Administering Z-Track Intramuscular Injection (102.075)
Administering Vaginal Medications (102.074)
Administering an Intradermal Injection (102.065)
Boniva Administration (Intravenous Bolus) (102.076)
Depo Provera Injections (102.077)
Imferon (Iron Dextran) (102.078)
Immunization Administration (102.079)
Immunotherapy (Primary Care Clinical Sites) (102.080)
Methotrexate Injection (102.081)
Racepinephrine (Racemic epinephrine) - High Alert Medication (102.082)
Reclast-Zoledronic Acid (102.083)
Fundus Measurement (102.084)
Hysteroscopy (Set-up and Clean-up) (102.085)
Ultrasound and Non-Stress Test Guidelines (102.086)
Measuring Fetal Heart Tones (102.154)
Bone Marrow Biopsy (102.087)
Paracentesis (102.088)
Cast Care (102.089)
Fractures: Assessment and Stabilization (102.090)
Joint Aspiration (102.091)
Joint Injection (102.092)
Measuring Crutches and Crutch Walking (102.093)
Skeletal Pin Care (102.094)
Blood Pressure Measurement (102.096)
Allied Health Adult Blood Pressure Visit (102.097)
Measuring Height in Adults and Children (102.098)
Assessing for Orthostatic Hypotension (102.099)
Measuring A Pulse (102.100)
Measuring Respiratory Rate (102.101)
Measuring Temperature (102.102)
Measuring Weight In Adults And Children (102.103)
Vision Screening (102.156)
Latex Screening (102.104)
Teaching Kegel Exercises (102.105)
Teaching Self Catheterization (102.106)
Teaching Testicular Self-Examination (TSE) (102.107)
Administering Oxygen (102.108)
Care of a Patient With a Tracheostomy (102.109)
Micro Mist Nebulizer (102.110)
Nasopharyngeal Suctioning (102.111)
Pulse Oximetry (102.112)
Competency Based Practice: New Employees (102.113)
Competency Based Practice: Annual Testing (102.114)
On-Site Learning Guidelines (102.117)
Student Placement Policy (placement and hire) (102.118)
Anoscopy and Proctoscopy (102.119)
Bowel Preparation/Instructions (102.120)
Breast Biopsy (102.121)
Hemorrhoid Banding Policy (102.122)
Vein Ligation (102.130)
Lipoma, Sebaceous Cyst and Skin Lesion Excisions (102.123)
Needle Localization Breast Biopsy (102.124)
Sigmoidoscopy (102.125)
Temporal Artery Biopsy (102.126)
Thrombosed Hemorrhoid Incision and Drainage (102.127)
Unna Boot (102.128)
Vein Injection (102.129)
Verruca Freeze For Condyloma (102.131)
Acyclovir Prescription (102.132)
Breast Expander Fill Procedure (102.133)
Lidocaine (EMLA) Cream Prescription (102.134)
Sciton Laser Policy (102.136)
Palomar Vectus Hair Removal Laser Policy (102.137)
Bladder Cancer Instillation-BCG or Thiotepa (102.135)
Bladder Scan (102.136)
Cystoscopy (Female) (102.137)
Cystoscopy (Male) (102.138)
Cystoscopy with Bladder Biopsy (102.139)
Cystoscopy/Retrogrades (102.140)
Meatotomy (102.141)
Prostate Ultrasound and Biopsies (102.142)
Urodynamic Complex Cystometrogram (CMG) Leakpoint and Pressures (102.143)
Vasectomy (102.144)
Animal Bites Treatment (102.145)
Bee Sting and Insect Bites (102.146)
Burns (102.147)
Changing a Dry Dressing (102.148)
Changing a Wet-to-Dry Dressing (102.149)
Frostbite (102.150)
Rabies Treatment and Follow-Up (102.151)
Snake Bites-Assessment and Treatment (102.152)
Wound Irrigation (102.153)
MF Couriers Cleaning of Specimen Transport Coolers (104.039)
Protocoling of Computed Tomography Angiography Exams and Magnetic Resonance Angiography Exams (112.001)
Use of OEC Mini View Imaging and Orthoscan HD - AFCH Systems (Flueroscan) (112.003)
Guidelines for Oral Contrast CT Scanning (112.004)
Pre-Medication Guideline (112.007)
Reporting of Contrast Reaction Guideline (112.009)
UW Health Clinical Policies (1.1.1)
Chain of Command for Concerns About Patient Care (1.3.1)
Reporting Unexpected Events and Determination of Sentinel Event Status (1.3.2)
Responding to Patient/Family Complaints and Grievances (1.3.3)
Emergency Detention – State Mental Health Act (1.2.1)
Involuntary Commitment – State Mental Health Act (1.2.2)
Opiate Management for Chronic Non-Cancer Pain (1.2.3)
No Further Service (1.2.6)
Suspected Child Abuse and Neglect (1.2.4)
Suspected Elder Adult and Adult-at-Risk Abuse and Neglect (1.2.5)
Suspected Domestic Violence and Abuse (1.2.7)
UW Health Patient Care Delegation Protocols (1.2.8)
Care of Patients Under Legal Custody (1.2.9)
Notification of Hospital Discharge Appeal Rights (1.2.10)
Reporting Patients Who May Be Unsafe Drivers (1.2.11)
Guardianship (1.2.12)
Organ and Tissue Donation (1.2.14)
Do Not Resuscitate (DNR)/No CPR Order (1.2.13)
Evaluation and Treatment of Patients Reporting Sexual Assault (1.2.17)
Advance Directives (1.2.15)
Medicaid Requirements for Surgical Procedures for Hysterectomies, Sterilizations and Abortions (1.2.18)
Consent for HIV Testing and Release of HIV Test Results (1.2.19)
Determination of Brain Death (1.2.16)
Notification of Hospital Discharge Appeal Rights (1.2.10)
Admission and Discharge Criteria for ICU Status on the Cardiothoracic Surgery and Transplant Unit (Acuity Adaptable Unit) (2.1.35)
Admission and Discharge Criteria for ICU Status at The American Center (2.1.24)
Admission and Discharge Criteria for IMC Status at The American Center (2.1.7)
Admission and Discharge Criteria for IMC Status in the Burn Unit (2.1.17)
Admission and Discharge Criteria for IMC Status on F6/6 (2.1.15)
Admission and Discharge Criteria for IMC Status on the Cardiothoracic Surgery and Transplant Unit (Acuity Adaptable Unit) (2.1.34)
Admission and Discharge Criteria for IMC Status on the Heart and Vascular Progressive Care Unit (2.1.4)
Admission and Discharge Criteria for Neuroscience ICU (2.1.26)
Admission and Discharge Criteria for the Burn Unit (2.1.16)
Admission and Discharge Criteria for the IMC Status in F4/4 (2.1.31)
Admission and Discharge Criteria for the Pediatric Universal Care Unit (2.1.5)
Admission and Discharge Criteria for Transplant IMC Status on B4/6 (2.1.32)
Admission and Discharge for Neonatal Intensive Care Unit (NICU) (2.1.30)
Admission and Discharge for Pediatric Intensive Care Unit (PICU) (2.1.33)
Admission and Discharge of Patients to and from D6/5 PCU (2.1.28)
Admission and Discharge of Patients to and from the Cardiac Intensive Care Unit (2.1.2)
Admission and Discharge of Patients to and from the Inpatient Psychiatric Unit (2.1.23)
Admission and Discharge of Patients to and from the Medical Cardiology Intermediate Care Unit (IMC) (2.1.3)
Admission and Discharge to and from the Trauma and Life-Support Center (2.1.18)
Admission of Patients Treated with Radiopharmaceuticals (2.1.19)
Admission, Care and Discharge of Patients to and from Inpatient Post-Anesthesia Care Unit (PACU) (2.1.9)
American Family Children’s Hospital (AFCH) Admissions (2.1.29)
Care of Emergency Department Patients Admitted to Hospital Services (2.1.1)
Care of Intubated ED Patients at the End of Life (2.1.21)
Care of the Adolescent Patient at The American Center (2.1.13)
Confidential Psychiatric Admissions and Notification of Release (2.1.20)
Discharge Planning Process (2.1.25)
Discharge Supplies (2.1.11)
Inter-hospital Transfer/Direct Admissions to UW Health (2.1.10)
Patient Belongings and Valuables (2.1.22)
Patient Reservations (2.1.36)
Patient Status During Hospitalization (2.1.37)
Patient Transfers (2.1.6)
Release or Detention of Voluntary Admission (2.1.14)
Transfer of the Decompensating Patient from The American Center (2.1.8)
Transport of Adult ICU Status Patients Within University Hospital (2.1.12)
Triage of Critically Ill Patients (2.1.27)
Suicide Assessment and Prevention (2.4.1)
Restraint and Seclusion (2.4.2)
Assault By a Combative Patient (2.4.3)
Suicide Evaluation and Intervention for Ambulatory Patients (2.4.4)
Grievance Policy and Procedure for Patients Receiving Care on the Psychiatric Unit or in an AODA or Behavioral Health Clinic (2.4.5)
Protective Custody and Involuntary Commitment for Persons Intoxicated and Incapacitated by Alcohol (2.4.6)
Blood and Blood Component Transfusion (Requiring Pre-Transfusion Testing) (2.2.6)
Caring for Patients Who Refuse Blood Transfusions (2.2.1)
Donation of Autologous/Directed Blood Products (2.2.4)
Human Tissue Standards (2.2.3)
Intraoperative Blood Salvage (2.2.5)
Massive Transfusion Protocol (Adult and Pediatric) (2.2.2)
Use of Containers for Clinical Specimens (2.5.1)
Collecting a Urine Specimen (2.5.2)
Pathology Examination of Patient Materials (2.5.4)
Lab Point of Service Testing (2.5.3)
Sending Test Results into UW Health Link via LabDE (2.5.5)
Blood Cultures for Adult Patients (2.5.6)
Drawing Venous Blood Specimens on Inpatients (2.5.7)
Blood Cultures for Pediatric Patients (2.5.8)
Administration of Mechanical Ventilation Via Artificial Airway (2.3.33)
Administration of Non-Invasive Ventilation (Commonly Referred to as BiPAP and NIV) (2.3.31)
Adult Procedural Sedation (2.3.29)
Assuring MRI Compatible Aneurysm Clips (2.3.9)
Deactivating Cardiovascular Implantable Electronic Devices (CIEDs) for Adult Inpatients (not during surgery or procedures) (2.3.26)
Discharge of Surgical Outpatients through Outpatient Surgery Center, First Day Surgery, and TAC Perioperative Services (2.3.4)
Electroconvulsive Therapy (ECT) (2.3.1)
Hospital School for the School Age Patient (2.3.22)
Inpatient Absence Policy (2.3.27)
Insertion, Maintenance, and Discontinuation of Central Vascular Access Devices for Prevention of Central Line-Associated Bloodstream Infection (CLABSI) (2.3.14)
Laboratory Specimen Care and Handling in Perioperative Care Areas (2.3.11)
Magnetic Resonance Imaging (MRI) Safety and Screening (2.3.5)
Mode of Patient Transport (2.3.18)
Monitoring Placement of Endotracheal Tubes Outside of the Operating Room and Other Anesthetizing Locations (2.3.34)
Operative Invasive Other Procedures (2.3.32)
Outpatient Discharge After Receiving Sedation (2.3.2)
Patient Care Before, During and After Minimal Sedation For Adult Patients (2.3.25)
Patient Care for Pediatric Patients Before, During, and After Minimal Sedation with Enteral Medications (2.3.24)
Pediatric Procedural Sedation (2.3.30)
Radiation Protection for Operating Room Staff (2.3.3)
Radioactive Eye Plaque Implants (2.3.7)
Radioactive Prostatic Seed Implants (2.3.8)
Recalled Equipment and Supplies in the Perioperative Areas (2.3.23)
Safe Transport of Sedated and/or Intubated Children in University Hospital (and AFCH) (2.3.13)
Scrub Attire (2.3.12)
Small-bore Nasoenteric (Dobhoff) Tube Placement (2.3.6)
Sterile Gowning and Closed Gloving in Perioperative Areas (2.3.15)
Subcutaneous Insulin Pump (Patient’s Own) and Continuous Glucose Monitor Use in the Hospital Setting (Adult and Pediatric) (2.3.19)
Suction (Wall Piped Vacuum) Outage - Perioperative Areas (2.3.10)
Surgical (Space) Helmet System Use and Clean-Up in Perioperative Areas Hospital Setting (Adult and Pediatric) (2.3.21)
The Use of Human Holders for Patients or Cassettes in X-Ray Procedures (2.3.17)
Traffic Control in Perioperative Areas (2.3.35)
Use of Hypo/Hyperthermia Blankets in Perioperative Areas Hospital Setting (Adult and Pediatric) (2.3.20)
Use of the Closed Circuit TV Monitoring System in Perioperative Areas (2.3.16)
Ventilator Parameter Adjustments (2.3.28)
Adult Trauma: Definition of a Trauma Patient (5.1.7)
Adult Trauma: Multi Victim Trauma Response at University Hospital (5.1.8)
Adult Trauma: Trauma Diversion (5.1.9)
Adult Trauma: Trauma Team Response at University Hospital (5.1.10)
Care of the Pregnant Trauma Patient in the Emergency Department at the University Hospital (5.1.3)
Defibrillation by BLS/ACLS/PALS Trained and Qualified Nurses and Clinical Exercise Physiologists (5.1.13)
Emergency Assessment at UW Health Facilities (5.1.1)
Emergency Response Teams (Adult and Pediatric) (5.1.16)
Evacuation of Staff and Patients from Locked Psychiatric Inpatient Unit (5.1.4)
Maintaining and Securing the Emergency Response Carts, Defibrillators and Automated External Defibrillators (AED) (5.1.15)
Pediatric Trauma (5.1.11)
Pediatric Trauma: Trauma Diversion (5.1.12)
Aseptic Technique Principles in Perioperative Areas (4.1.12)
Assessing Sterility of Packaged Items at Point of Use (4.1.20)
Cleaning of Blood and Body Fluid Spills (4.1.4)
Cleaning of Toys, Therapeutic and Entertainment Activity Items (4.1.18)
Cleaning, Disinfection and Sterilization of Patient Care Devices and Equipment (4.1.7)
Communicable Disease Exposure Response (4.1.6)
Control of Tuberculosis (4.1.1)
Endoscope Reprocessing (4.1.11)
Hand Hygiene (4.1.13)
Healthcare Worker with Bloodborne Pathogen Infection (4.1.9)
Infection Control in the Cystic Fibrosis Patient Population (4.1.2)
Investigation of a Potential Epidemic (4.1.5)
Management of Exposure to Blood or Body Fluid (4.1.17)
Precautions for Immunocompromised Patients (Protective Precautions) (4.1.19)
Precautions for Transmissible Spongiform Encephalopathy (CJD and other prion diseases) (4.1.15)
Response to Failed High Level Disinfection or Sterilization Cycle (4.1.14)
Restriction on Reprocessing Single Use Devices (SUDs) (4.1.16)
Sharps Disposal (4.1.10)
Standard Precautions and Isolation (4.1.8)
Hand-Off Communication (3.3.1)
Live Interactive Video Telemedicine for UW Health (3.3.2)
Ambulatory Patient No Show, Late Cancellation and Late Arrival (3.3.3)
Interpreter Services and/or Language Assistance (3.3.4)
Participation of Patients’ Primary Supports and Visitors (3.3.5)
Communication of Critical Results and Critical Tests/Procedures (3.3.6)
Remote Clinical Practice Utilizing Live Interactive Video Telemedicine (3.3.7)
Disposition of the Body After Death (3.3.8)
Death Reports to the Coroner (3.3.9)
UW Health Ambulatory Childhood Vaccine Refusal (3.1.1)
Adult Patient Acknowledgement of Voluntary Inpatient Psychiatric Admission and Alternative Procedures (3.1.2)
Patient Identification (3.2.1)
Use of the Controlled Substance Alert Within the Medical Record (3.2.2)
Expectations for DONEING of Results Messages by Authorizing Provider (3.2.3)
Entering Test Results into UW Health Link (EPIC) (3.2.4)
Inpatient Health Link Downtime and Recovery (3.2.6)
Unidentified Patient (3.2.7)
Ambulatory Health Link Downtime and Recovery (3.2.5)
Newborn Naming (3.2.8)
Clinical Alarm Management and Response (3.5.3)
Pain Management (3.5.5)
Patient and Family Education (3.5.4)
Recording and Review of X-Ray Exposure for Procedures Using Fluoroscopy (3.5.6)
Screening of Possibly Pregnant, or Pregnant Patients Prior to Diagnostic Radiological Exam (3.5.1)
Screening, Assessment and Reassessment of Patients (3.5.2)
Diet Orders (3.4.1)
Patient Care Orders (3.4.2)
Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation, and Patient/Family Education (6.1.1)
Intravenous Patient Controlled Analgesia (PCA) for Adult and Pediatric Patients (6.1.2)
Intrathecal Chemotherapy Ordering, Administering (6.1.3)
Control of Samples: Medications, Personal Medical Devices, Drug Vouchers and Starter Supplies (6.1.6)
UW Health Formulary Restricted Clinic Administered Medication Pharmacy Department Review and Use of Non-UW Health Supplied Medications Administered in Clinics (6.1.5)
Management of STAT Medications for Inpatient Units (6.1.7)
Administration of Intravenous Medications (6.1.8)
Restricted Primarily Ambulatory Administered Medications in Hospitalized Patients (6.1.9)
Medication Reconciliation (6.1.10)
UW Health Pharmacy and Therapeutics Committee Organizational Policy (6.1.4)
Preventing Non-therapeutic Exposure to Hazardous Drugs ( 6.1.11)
Controlled Substance Control Systems in Patient Care Areas (6.1.13)
Use of a Patient’s Own Medication Delivery Device (6.1.12)
Approval of Core and Patient-Specific Chemotherapy Regimens for the Treatment of Adult Malignancy (6.1.14)
Epidural and Intrathecal (Neuraxial) Analgesia (6.1.15)
Antimicrobial Stewardship Program (6.1.16)
Infectious Diseases Section Approval of Restricted Antimicrobial Agents (6.1.17)