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Policies,Clinical,UW Health Clinical,General Care and Procedures,Admission, Discharge, Transfer

Patient Belongings and Valuables (2.1.22)

Patient Belongings and Valuables (2.1.22) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer

2.1.22


UW HEALTH CLINICAL POLICY 1
Policy Title: Patient Belongings and Valuables
Policy Number: 2.1.22
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: October 25, 2016

I. PURPOSE

To provide guidance regarding the loss or damage of patients’ valuables and belongings and to comply with
any related regulations throughout UW Health (UWH).

II. DEFINITIONS

A. Non-essential valuables are defined as personal property that has greater monetary value, e.g., jewelry,
cash in sums greater than $25, credit cards, cell phones and electronics.
B. Essential valuables are those items that are needed for activities of daily living e.g., hearing aids, corrective
lens, dentures.
C. Belongings are defined as clothing and other personal items.

III. POLICY ELEMENTS

A. Patients will be instructed during pre-procedure/admission teaching by ambulatory clinic or
outpatient/ambulatory procedure staff to leave nonessential valuables and belongings at home. For
emergent/urgent procedures/admissions the authorized representative (e.g., family member or person
accompanying the patient) will be asked to assume responsibility for belongings/any valuables by admitting
nursing staff or delegate.
B. Health Facts For You (HFFY) #7495 will be provided to the patient or authorized representative during the
pre-operative teaching for scheduled admissions or upon admission to the nursing unit or procedural
area/Emergency Department if urgent or emergent. HFFY #7495 is included in hospital admission packets.
C. For patients being admitted, belongings/valuables not going home with patient’s authorized representative
will be documented in the clinical record on the Patient Belongings List and a report will be printed for the
patient or authorized representative. Staff will strongly recommend that any valuables not being sent home
should be sent to University Hospital (UH) / American Family Children’s Hospital (AFCH) Admissions or The
American Center (TAC) main safe to secure for safekeeping. When belongings/valuables are not secured
in UH / AFCH Admissions / TAC main safe or sent home, staff will inform the patient or authorized
representative that s/he is responsible for those items and document in the clinical record.
D. Completion and verification of the Patient Belongings List and printing of the report for the patient or
authorized representative is the responsibility of the admitting nurse or delegate for every patient admission,
transfer and discharge.
E. Any amount of cash, credit cards, jewelry and other valuables being sent to UH / AFCH Admissions / TAC
main safe for safekeeping will be documented in the clinical record on the Patient Belongings List and on the
Patient Valuables form prior to sending. A copy of the completed form will be provided to the patient or
authorized representative.
F. If it is determined that a patient’s belongings/valuables are missing, the staff member who first became
aware of the lost item(s) shall initiate a search. If the item(s) are not found, the staff member will report to
the Nurse / Department Manager or Care Team Leader (CTL) who will investigate further by interviewing
other staff who have had contact with the patient and alert staff to look for the missing item(s).
G. If unable to find essential valuable(s), and the patient or authorized representative indicates they wish to file
a complaint, staff will provide the Patient Relations Department contact information (business card) or call
263-8009. Staff will not guarantee or suggest that compensation will be provided for lost item(s).
H. For items alleged by the patient or authorized representative to be stolen, contact Patient
Relations/Resources and Security Department.

IV. PROCEDURE FOR CARE OF VALUABLES AND BELONGINGS

A. Admission to Inpatient Care Units
i. The admitting nurse or delegate will document all patient belongings and valuables (including those
sent to the safe) in the clinical record within 4 hours of admission.
ii. Belongings will be placed in a patient labeled belongings bag or essential valuables will be placed
in a labeled Personal Belongings Case (dentures, eyeglasses, hearing aids). Patient labels should



UW HEALTH CLINICAL POLICY 2
Policy Title: Patient Belongings and Valuables
Policy Number: 2.1.22

be placed on any additional belongings, e.g., power cords, chargers and provided to the patient or
authorized representative as needed.
iii. Valuables being sent to the safe are documented on the labeled Patient Valuables Form.
a. The admitting nurse or delegate will complete the Valuables Form which is then signed by
the patient or authorized representative and the witnessing nurse or delegate.
b. The valuables will be placed into the tamper-proof valuables envelope along with the copy
of the valuable form labeled “Place in Valuables Envelope.” The envelope is then sealed.
c. The nurse or delegate will place the adhesive (bottom) copy of the Valuables Form on the
valuables envelope to clearly identify the owner of the property.
d. The designated “Copy for the Paper Medical Record” of the Patient Valuables Form is
filed in the paper medical record or scanned (if unit scanner available) into the electronic
clinical record and the “Copy to the Patient or Authorized Representative” is provided to
the patient/authorized representative.
e. The patient valuables envelope is deposited into a lock box located on the UH /AFCH
inpatient unit for Security to pick up on their rounds. At TAC, Security is contacted to pick-
up to take to main safe. If the envelope will not fit into the lock box, contact Security to
take the valuables envelope directly to Admissions for safekeeping.
f. Security staff will round each day to retrieve patient valuables from the unit lock boxes.
g. Admissions staff will document in the patient registration record the date valuables
received, date valuables released and the person to whom the valuables were released.
iv. If a patient refuses to comply with a listing of belongings/valuables and staff are concerned about
safety, e.g. weapons, they are to contact Security for assistance. If staff are concerned that patient
is harboring medications, e.g. controlled substances, staff should confer with the Care Team
Leader and contact the Attorney-On-Call if necessary. Security will search the room and request
the patient’s permission to go through the belongings/valuables with them. If patient refuses,
Security will instruct patient that items will need to be secured based on concerns for safety.
Security will secure items either in Admissions or Security Office until patient is discharged.
Security will contact law enforcement if they determine it is necessary.
v. AFCH staff will instruct parents/legally authorized representative regarding locked cabinet in patient
room for belongings/valuables storage as well as option to have valuables sent to Admissions for
safekeeping. Parents or legally authorized representative will also be instructed that they are
responsible for items kept at the bedside for minor children. General procedures are followed as
noted in IV. A. i-iv.
B. Intrahospital Transfer of Patient Belongings
i. ED: Patient or authorized representative will be responsible for belongings/valuables unless
admitted at which time the belongings/valuables will be documented by the ED staff and follow
IV.A.i-iv. If the patient is going directly to the Operating Room (OR), the patient’s belongings will be
stored in the ED and delivered to the inpatient nursing unit by ED Volunteer Services after the
patient is admitted to the nursing unit.
ii. For any transfers between inpatient nursing units, the transferring unit will provide the valuables
paper medical record copy or refer to the scanned copy and labeled patient belongings to the
receiving unit. The receiving nurse or delegate will place the valuables form in the paper medical
record and reconcile the belongings with the patient belongings documentation in the clinical record
and document items have been reconciled. If there are any discrepancies, the nurse or delegate
will investigate e.g., contact the transferring unit to determine if the item(s) are still on the unit
C. Discharge from UH, AFCH, and TAC:
i. At UH and AFCH Unit staff will remind patient/family members to retrieve any valuables in
Admissions prior to discharge/at TAC staff will contact Security to bring patient’s valuables to the
patient’s room. The patient or the patient's authorized representative must show identification or the
“Patient or Patient Representative” Valuables Form copy in order to retrieve/receive valuables.
After the valuables have been retrieved and signed for by the patient/ patient authorized
representative, UH / AFCH Admissions staff scan the Patient Valuables Form into the hospital's
document imaging system and document the date released into Documents and Patient
Information in the clinical care.
ii. If valuables are left behind in UH /AFCH Admissions or TAC main safe, they will contact
patients/family regarding return of valuables and make appropriate arrangements for the
patient/family to pick up the valuables in Admissions or mail the valuables, and document on the
Valuables Form which is then scanned along with any accompanying documentation e.g., certified



UW HEALTH CLINICAL POLICY 3
Policy Title: Patient Belongings and Valuables
Policy Number: 2.1.22

mail receipt.
iii. If the belongings are found after discharge, staff will bring any items left behind to the unit desk
immediately for labeling with the patient’s name and medical record number (MRN). The items will
be turned over to the appropriate Lost and Found Staff e.g., Environmental Services Supervisor
who will transport the items to the Lost and Found location for mailing to the patient or authorized
representative.
iv. To turn in found valuables, contact Hospital Security (UH / AFCH - 890-5555; TAC - 440-6666). A
Security Officer will pick up the patient valuables where they will be secured in the Security Office
and arrangements will be made with the patient or authorized representative to pick them up or
have them mailed.
D. Handling of Contaminated Patient Belongings/Valuables. Any patient property that is soiled with blood or
body fluids shall receive special handling.
i. Garments soiled with blood or body fluids should be placed in a red biohazard bag and then a
belongings bag for retention until patient discharge, or may be discarded if requested/permitted by
the patient or patient’s authorized representative.
ii. Contaminated patient valuables will be placed in a biohazard Ziploc bag (i.e., laboratory bag) that is
then placed inside the tamper-proof valuables envelope. The staff member handling the valuables
shall check the “potentially contaminated patient valuables” box on the Patient Valuables Form.
This designation will alert Admissions staff NOT to open the plastic bag inside the valuables
envelope when contaminated valuables are reclaimed.
E. Release of Belongings/Valuables in the Case of Death
i. No belongings/valuables should accompany the body to the morgue. Exception would e.g., ring on
hand that not able to remove or authorized representative has requested it remain on. This should
be noted in the clinical record
ii. Emergency Department: Any belongings released to the authorized patient representative will be
placed in a labeled patient belongings bag and documented in the clinical record. If no authorized
patient representative is present to accept patient belongings/valuables at the time of the patient’s
death, the patient valuables will be placed in a tamper-proof envelope with the Patient Valuables
Form copy labeled “Place in Valuables Envelope” and secured in the locked box in the ED. Security
will retrieve valuables on their rounds and take to Admissions for safekeeping. Admissions will work
with Patient Relations as needed to contact the authorized patient representative to pick up or have
mailed. Patient belongings will be placed in a labeled patient belongings bag along with the
name/address /phone number of the emergency contact and sent to UH / AFCH Lost and Found
(D6/125); TAC – American Center Security Control Room. If staff do not know who the belongings
should go to, Lost and Found will work with Patient Relations to determine disposition.
iii. Patient Care Unit: The patient’s authorized representative should retrieve the patient’s valuables
from UH/AFCH Admissions or TAC Security per IV.C.iii. Patient belongings should be given to the
next of kin, if available, or sent to Lost and Found in a labeled patient belongings bag with the
name/address/phone number of the emergency contact. Disposition of items is documented in the
Patient Belongings list in the clinical record.

V. PROCEDURES FOR SPECIFIC PATIENT CARE AREAS

A. UH/AFCH Emergency Department (ED)
i. For patients being admitted, the ED nurse or their delegate will document patient
belongings/valuables in the clinical record and for valuables going to UH / AFCH Admissions / TAC
main safe for safekeeping will document on the Patient Valuables form. Refer to IV. A-B. for
general procedure.
ii. If no authorized patient representative is present and the patient is unable to sign the Patient
Valuables Form, it is recommended that two employees document the patient's belongings and
valuables. The names of the employees should also be documented on the Patient Valuables
Form. The adhesive Valuables Form copy should be adhered to the tamper-proof envelope and
the envelope placed in the secured lock box in the UH/AFCH ED / contact TAC Security to pick-up.
Security staff will pick-up valuables from the locked-box on their rounds and take to Admissions for
safekeeping. Patient clothing and other belongings are placed in the "Patient's Belongings Bag"
labeled with patient name and turned over to the inpatient admitting nurse/ delegate at UH/AFCH /
placed in storage room on dedicated Overnight Care shelf at TAC
iii. Patients Transferred Directly to the OR. Refer to IV.B.i. The Care Team Leader or ED Coordinator



UW HEALTH CLINICAL POLICY 4
Policy Title: Patient Belongings and Valuables
Policy Number: 2.1.22

will provide the ED volunteer with the assigned patient rooms for delivery of the patient
belongings. Patient Valuables will be handled the same as in V.A.i.
iv. Patients evaluated in the ED but being discharged directly from the ED will have their belongings
returned to them in the labeled Patient Belongings bag prior to discharge.
B. Inpatient OR
i. When a patient's valuables (e.g., piercings) are removed in the OR, the staff will document in the
clinical record peri-operative checklist the item and disposition. The valuables will be given to the
patient’s authorized representative. If there is no authorized representative, the valuable will be
documented on the Patient Valuables Form and secured in the tamper-proof valuables
envelope. The copy of the form labeled “Place in Valuables Envelope” will be placed in the
envelope and the envelope will be sealed. The envelope will then be stored in a lock box in the OR
throughout the duration of the patient's surgery. Security staff will pick up patient valuables on their
rounds and deliver to Admissions for safekeeping. If the valuable is too large to place in the locked
box, Security will be contacted to retrieve the valuable and take to Admissions for safekeeping.
ii. Patient belongings, e.g., dentures, will be documented on the clinical record peri-operative
checklist, placed in a patient labeled sealed container and given to the patient’s authorized
representative or if coming from an inpatient unit, the unit staff will be contacted to retrieve the
belonging and return it to the patient’s room on the unit.
C. First Day Surgery (FDS)
i. Patients are contacted pre-operatively and instructed to leave all valuables at home and if they
choose to bring non-essential valuables, they will be responsible for their safekeeping.
ii. Patients admitted to FDS will have belongings placed in the patient belongings bag, labeled with
the patient’s label, and documented in the clinical record. Belongings in patient’s own bag (e.g.,
suitcase, duffle bag) and not individually itemized in the electronic documentation, but noted as
number of bags i.e., 1 black duffle, no valuables per patient. The patient belongings bag is then
placed in the patient belongings Room 12. The RN/NA places a patient label along with a
description of belongings on the FDS Patient Belongings Checklist for delivery to the nursing unit
where the patient will be going after surgery. Assistive devices (e.g., crutches, wheelchairs) are
also labeled and delivered if the patient/family/authorized patient representative desires.
iii. For Identified valuables see IV.A. iii.
iv. A float Nursing Assistant (NA) will pick up the patients’ belongings from FDS Room 12 daily
(usually between 4-6 p.m.) to deliver to the appropriate nursing units. Patient locations are either
gathered from the Post Anesthesia Care Unit (PACU) assignment sheet or by looking up the
location of the patient in the computer. The NA takes the FDS Patient Belonging Checklist along
with the patients’ belongings to the designated nursing units.
v. Unit staff are required to sign the FDS Patient Belongings Checklist verifying receipt of the
belongings.
D. UH Outpatient Surgery Center (OSC) and AFCH OR
i. Patients are contacted pre-operatively and instructed to leave all valuables at home and if they
choose to bring non-essential valuables, they will be responsible for their safekeeping.
ii. Patients admitted and discharged from OSC will have belongings placed in a patient belongings
bag, labeled with the patient label and either left in the patient’s assigned pre/post-op bay or given
to the authorized patient representative accompanying the patient. Valuables are either secured on
the patient (i.e., rings) or provided to the authorized representative.
iii. Patients admitted from OPC will have belongings and valuables handled in the same manner as
FDS (see V.C.).
E. UH Ambulatory Procedure Center (APC), Digestive Health Center (DHC)
i. Patients are instructed to use the lockers in gowned waiting area for their belongings/valuables.
ii. A key is provided for each locker and is on a coiled key chain so the patient can wear it on the wrist
until the appointment is complete.
iii. When the appointment is complete the patient retrieves belongings/valuables and leaves the key in
the lock for the next person.
iv. If the patient is admitted from the APC, the patient’s belongings are placed in a labeled patient
belongings bag and sent with the patient to the unit. Items such as dentures, eyeglasses or hearing
aids are either placed on the patient, placed with the other belongings in a labeled personal
belongings case and then in the labeled belongings bag or given to the patient’s authorized
representative.
F. UH Radiology and Breast Center



UW HEALTH CLINICAL POLICY 5
Policy Title: Patient Belongings and Valuables
Policy Number: 2.1.22

i. Patients are instructed to use the lockers in gowned waiting area for their belongings/valuables.
ii. A key is provided for each locker and is on a coiled key chain so that patient can wear it on the
wrist until the appointment is complete.
iii. When the appointment is complete the patient retrieves belongings/valuables and leaves the key in
the lock for the next person.
G. Hospital Outpatient Departments
i. If a patient is admitted from a hospital outpatient department (e.g., Infusion Center, Hemodialysis,
Cardiac Catheterization) the patient belongings/valuables list may be initiated in Health Link
following the same procedural steps as outline in IV.A.
H. UWH Ambulatory Clinics
i. Patients are responsible for their belongings / valuables during ambulatory clinic visits. If any items
are found, they should be sent to the locations designated Lost and Found and labeled if owner
known. If patient or authorized representative reports a missing item(s), refer them to the
designated Lost and Found for that ambulatory clinic location.

VI. FORMS FOR DOCUMENTATION OF BELONGINGS/VALUABLES

Patient Belongings in the clinical record
Patient Belongings Downtime Form
Patient Valuables Form

VII. REFERENCES

Wis. Admin. Code chapter DHS 13, Reporting and Investigation of Caregiver Misconduct, which requires
reporting of misappropriation of patient property.
UWHC Administrative policy #4.47, Caregiver Misconduct and Reporting

VII. COORDINATION

Author: Director, Risk Management
Senior Management Sponsor: SVP, General Counsel
Reviewers: Director of Patient Relations; Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: August 15, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VIII. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

IX. REVIEW DETAILS
Version: Revision
Next Revision Due: October 2019
Formerly Known as: Hospital Administrative policy #7.27, Management of Patient Belongings