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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Restricted Areas
Policy Number: 1.15
Effective Date: 06/01/2017
To establish procedures regarding access to restricted areas for UW Health properties. Restricted areas
refer to areas limited in access to authorized personnel only.
II. POLICY ELEMENTS
A. There shall be designated "Restricted Areas" within UW Health facilities that are accessible only
to authorized personnel. UW Health employees, medical staff and students (and other persons
authorized under the Medical Staff Bylaws to provide patient care in UW Health facilities) are
authorized to enter restricted areas that are necessary for their work related or training activities.
All other individuals must have the authorization of the department director or hospital
administration before entering a restricted area, except that (a) patients are authorized when
authorized personnel determine that the patient needs to be in the area for diagnosis or treatment
and (b) visitors to patients are authorized when acting within the scope of the visiting rules
applicable to the area and infectious disease policy.
B. "Restricted Areas" within UW Health are designated for many reasons, including:
1. To protect the safety of employees, medical staff, students, patients and visitors. Example -
Unauthorized individuals are not allowed in the hospital basement due to the presence of
2. To protect patient confidentiality. Example - Health Information Services area is designated
as a restricted area with limited accessibility to protect the confidentiality of patient health
A. All unauthorized individuals will be required to leave a restricted area immediately. If they refuse
to comply, Security or site supervisor will be asked to escort them from the area.
B. If an unauthorized individual is invited into a restricted area by an employee, medical staff
member, student, or other authorized individual without the express authorization of the
department director or hospital administration, that authorizing individual will be subject to
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C. The following areas within UW Health facilities have been designated as "Restricted - Authorized
Personnel Only". The list is not all inclusive and other areas may be added at the discretion of the
department director, Security Director or hospital administration. Where appropriate, restricted
areas will be posted.
1. Core Supply Areas
2. Ambulatory Surgery
3. Basement - Mechanical Areas
4. Blood Bank
5. Cash Handling Rooms
6. Cardiac Catheterization Lab
7. Central Service
8. Clinical Laboratories
9. Data Center(s), Computer Rooms, Data Rooms
10. Decontamination Areas
11. Food Service
12. Health Information Services File Room
13. Imaging Areas
14. Interstitial Space
15. Med Flight
16. Medication Lock Boxes
17. MRI Suite
18. Operating Rooms
19. Orthotics Lab
20. Pathology Laboratories
21. Patient Care Areas
23. Radiology Treatment Rooms
24. Radiotherapy Treatment Rooms
25. Recovery Rooms
26. Roof Areas
D. Access into restricted areas is typically controlled by card readers, electronic alarms, and/or door
1. Managers requesting access to restricted areas on behalf of their staff for electronic card or
key access should submit the online Security Access Request Form found on U-Connect in
the Manager's Toolkit or Security Services or Facilities and Engineering’s department
a. The Pharmacy Department manages their staff's card reader access to medication storage
locations (i.e. medication rooms, pharmacies, etc.) using the Pharmacy Departments
i. Designated Pharmacy staff are responsible for updating the database which
automatically sends an access request to Security.
2. Card reader access will be issued to staff by the Security Department.
a. Card reader access must first be authorized by the employee’s department manager
followed by review and authorization from the designated manager, or delegate of the
b. Card access may be issued to non-employees for temporary situations, provided that the
access end-date does not exceed a period of 30 days. Card access renewals for non-
employees will be limited to 30-day increments.
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i. Managers should contact the Security Department by Email: UWHC Security
Department or by telephone: 890-5555 to request/authorize non-employee card
access for special projects.
3. Key requests are reviewed and authorized by the Security Department, in accordance to
Administrative Policy 12.57-Key Control.
a. Keys should not be issued permanently to non-employees, volunteers, or contractors. If
keys are required for non-employees on a temporary basis for projects, the keys must be
signed out by Facilities and Engineering Services.
E. The Security Services department should annually provide managers of restricted areas a list of
employees and non-employees who have badge access to their restricted area. Managers should
update Security with any additions or removals of access to the restricted area.
F. Generic badges should be used in limited situations and with the approval of the director of
Security Services. Periodic reviews of the usage will occur by the Security Department.
G. On a quarterly basis Security Services will review master badge access profiles in the access
Sr. Management Sponsor: VP, Facilities and Support Services
Author: Director, Security Services
Reviewer(s): Director, Hospital & Support Services at The American Center; Manager, Safety
Approval Committee: UW Health Administrative Policy and Procedure Committee
UW Health Chief Administrative Officer
Previous revision: 07/01/2016
Next revision: 06/01/2020