Resident and Fellow Policy Manual
Strong Memorial Hospital Policies:
The Strong Memorial Hospital Policy Manual is the principal administrative policy reference for Hospital faculty and staff. Individual department or unit manuals within the Hospital must be consistent with policies contained in this manual, which is the official statement of Strong Memorial Hospital policy.
Each policy in the manual has been reviewed thoroughly and revised, as appropriate, by the Policy Management Team, an interdisciplinary work group convened for this purpose. Each policy has been reviewed and recommended for approval by the SMH Clinical Council or when appropriate, by the Hospital's Management Team.
Although these policies have passed through a thorough review process, there will be situations that Hospital policy does not address or when policy seems ambiguous. In these situations, these policies are provided as general guidelines. In all cases, Hospital faculty and staff should adhere to professional judgment regarding the safety of patients, visitors, and staff, and the treatment of patients.
Suggestions for addition of new or revision of existing policies should be submitted to the Director of the Quality Assurance Office. Revised and new policies are posted monthly and are distributed periodically to manual holders. The Update section is provided to highlight changes within the prior six months. Questions or problems regarding the intent or implementation of policy in specific situations should be addressed through normal supervisory channels.
The policy manual can be found on the URMC intranet under Administrative Services, Policy Manual - SMH.
Strong Memorial Hospital Policy Manual Table of Contents
1. General Information
1.1 - Mission Statement
1.2 - History of Strong Memorial Hospital(SMH)
1.3 - Administrative Organization (SMH)
1.4 - Administrator-On-Call
1.5 - Grid System
1.6 - Departmental Policy Development and Review
1.7 - Code of Organizational and Business Ethics
1.7.1 - Code of Conduct
1.8 - Policy Development, Review and Approval
2. Emergencies
2.1 - Blue 100
2.1.1 - Pediatric Emergency Response (Pediatric Team)
2.2 - Medical Emergency Response Team (MERT)
2.3 - Condition Gray
2.4 - Fire and Emergency Evacuation
2.5 - Emergency Preparedness Plan
2.6 - Obtaining Security Assistance
2.7 - Emergency Medical Treatment, Screening, Stabilization and Transfer [EMTALA/COBRA]
2.8 - Infant or Child Abduction - Code Pink
2.9 - Condition Yellow
2.10 - Code 1-1 (One Hour Warning)
3. Admissions
3.0 - General
3.1 - Patient Accommodations
3.2 - Admission Testing
3.3 - Protection of Minor Patients
3.3.1 - Newborn
3.3.2 - Infants on Adult Inpatient Units
3.4 - Legal Status for Psychiatric Patients
3.5 - Special Care Units
3.6 - Admission from the Ambulatory Surgical Unit
3.7.1 - Transfers Into SMH
3.7.2 - Transfers Within SMH
3.8 - Hospice Patients
3.9 - Charity Care
4. Discharges
4.1.1 - Discharge Planning
4.1.2 - Interdisciplinary Risk Screening - Discharge Planning for Inpatient Services
4.2 - Psychiatric
4.3.1 - Newborns
4.3.2 - Minors
4.4.1 - Therapeutic Day Passes
4.5 - Against Medical Advice (AMA)
4.6 - Patient Disappearance
4.7 - Transfer and Transport of ED and Inpatients to Other Healthcare Facilities
5. Death
5.1 - Determination of Death
5.2 - Consent for Autopsy
5.3 - Fetal Death
5.4 - Medical Examiner's Cases
5.5 - Release/Disposal of Body
5.6.1 - Anatomical Gift Program Donation of Whole Body
5.6.2 - Donation of Organs and Tissues
5.7 - Care of Body at Death - Religious/Cultural Concerns
6. Medical Records
6.0 - General
6.1.1 - Completion of Medical Records
6.1.2 - Completion of Medical Records - Ambulatory Surgical Unit
6.2.1 - Confidentiality, Release of Patient Information, and Removal of Records
6.2.2 - Confidentiality and Release of HIV and/or AIDS Patient Information
6.2.3 - Confidentiality and Release of Alcohol or Drug Abuse Patient Information
6.3 - Approved SMH Forms
6.3.1 - Computerized Provider Order Entry: Order Set Approval
6.4 - Medical Abbreviations
6.5.1 - Changes/Corrections
6.5.2 - Name Changes
6.6 - Documentation of Surgical or Anesthesia Complications-AmbulatorySurgical Unit
6.8 - Information Systems Security
6.10 - Retention Period and Destruction Process for Patient Medical Records
6.11 - Medical Record Documentation: Summary Lists
7. Medication Standards
7.1 - Medication Use
7.3 - Medications and Dietary & Herbal Supplements Belonging to Patients
7.4 - Prescription Medications for Individuals Who Are Not Patients
7.5 - Restricted Antibiotics
7.6 - Controlled Substances
7.7 - Investigational Drugs
7.8 - Purchasing
7.9 - Pharmaceutical Company Representatives
7.10 - Antineoplastic and Other Toxic Agents - Guidelines for Handling
7.10.1 - Aerosolized Pentamidine Treatment
7.11 - Admitting Drug Orders
7.12 - Medication Order Writing by Uncredentialed Residents
7.13 - Parenteral Medication Orders
7.14 - Ribavirin - Guidelines for Handling
7.15 - Hold Orders
7.16 - Drug-Nutrient Interaction
7.17 - Adult Systemic Antineoplastic Chemotherapy Orders
7.17.1 - Pediatric Systemic Antineoplastic Chemotherapy Orders
7.17.2 - Administration of Antineoplastic and Biologic Agents
7.18 - Nonpatient-Specific Immunization Orders for Inpatients
8. General Patient Care
8.1.1 - Patient Care Orders
8.1.2 - Verbal Patient Care Orders
8.1.4 - Interdisciplinary (Support Service) Screening Assessment, Care Planning and Patient Teaching Processes
8.1.5a - Order Entry Procedure for Scheduled Downtime of the Clinical Information System
8.1.5b - Order Entry Procedure for Unscheduled Downtime of the Clinical Information System
8.2 - Required Tests/Procedures
8.3 - Inpatient Suicide Risks - in a Non-Psychiatric Setting
8.4 - Reportable Diseases/Infections/Conditions
8.5 - Physician Consultations/Referrals
8.6 - Tissue Specimens from Outside Institutions
8.7.1 - Inpatient Utilization Review
8.7.2 - Currently Not an Assigned Policy Number
8.8 - Review and Evaluation of Blood Utilization
8.9 - Clinical Laser Privileges
8.10.1 - Interim Privileges
8.10.2 - Emergency Privileges
8.11 - Use of Moderate & Deep Sedation
8.11.1 - Privileging Physicians and Mid-Level Providers for Administration of Moderate or Deep Sedation
8.12 - Point of Care and Off Site Laboratory Tests
8.13 - Education of Patients and Families
8.14 - End of Life Care and Planning
8.15 - Pain Management
8.16 - Clinical Laboratory Specimen Labeling Requirements
8.17 - Feeding Tube Placement Confirmation for Adults
8.18 - Use of Fluoroscopy
8.19 - Imaging Sciences Services: Hospital to Hospital Adult Patient Transfer
9. Medical/Legal
9.1 - Incident Reports - Patients and Visitors
9.1.1 - Reporting of Actual and Potential Medical Events
9.1.2 - Disclosure of Unanticipated or Negative Outcomes
9.2.1 - Informed Consent
9.2.3 - Consent for Sterilization
9.2.4 - Participation of Human Subjects in Research
9.2.5 - Photographing, Filming or Recording of Patients
9.3 - Advance Directives
9.3.1 - Health Care Proxies
9.3.2 - Do Not Resuscitate (DNR)
9.3.3 - Withholding/Withdrawing Unwanted Life-Sustaining Medical Care
9.3.4 - Ethical Issues
9.4 - Abortions
9.5 - Health Care to Minors
9.6 - Wounds/Removal of Foreign Body
9.7 - Sexual Assault
9.8 - Blood Tests for Drug or Alcohol Content - Law Enforcement Requests
9.9 - Contacts With Law Enforcement Agencies
9.10 - Patient Prisoners
9.11.1 - Suspected Child Abuse or Maltreatment
9.11.2 - Contacts With Law Enforcement Agencies in Matters of Child Abuse or Maltreatment
9.11.3 - Medical Care for Handicapped Newborns and Infants
9.11.4 - Adult Domestic Violence
9.11.5 - Suspected Abuse of Patients from Residential Health Care Facilities
9.11.6 - Elder Abuse and Neglect
9.12 - Requests for Medical Information for Legal Purposes
9.13 - Subpoenas and Other Requests for Interviews or Other Information
9.14 - Summons
9.15 - Adoptions
9.17 - Witnessing Signatures
9.18 - Refusal of Blood Transfusion (or Blood Products)
10. Patient/Public Health and Safety
10.1.1 - Patient Identification Bands
10.1.2 - Patient, Procedure and Site Verification
10.2 - Restraints (In Non-Psychiatric Settings)
10.2a - Restraints and Seclusion (Department of Psychiatry Policy 5.3; for information)
10.3 - Smoking
10.4 - Alcoholic Beverages
10.5 - Non-Patient Care Electrical Equipment
10.6 - Unsafe Product/Equipment Report
10.7 - Animals
10.8.1 - Currently Not An Assigned Policy Number
10.8.2 - Keys for Narcotic Cabinets
10.9 - After Hours Entry
10.10 - Firearms/Weapons
10.11 - Windows
10.12 - Infection Prevention and Control
10.13 - Non-Personnel Exposure to Bloodborne Pathogens - Post Exposure Evaluation and Follow-Up
10.14 - Workplace Violence
10.15 - Equipment Management Policy
10.16 - Suspected Illegal Drugs Confiscated from Patients
10.17 - Safe Use of Equipment in an Oxygen Enriched Environment
10.18 - Safe Disposal of Single Use Cautery Devices
11. Patient Relations
11.1.1 - Patient Rights
11.1.2 - Patient Rights - Psychiatric
11.2 - Visitors & Visiting Hours
11.3 - Religious Practices
11.4 - Care of Personal Belongings
11.5.1 - Interpreters - Spanish and Other Languages
11.5.2 - Interpreters - Hearing Impaired
11.5.3 - Interpreters - Spoken Languages other than Spanish
11.6 - Telecommunication Services for the Deaf and Hearing Impaired
11.7 - Complaints
12. External Relations
12.1 - Contacts by External Agencies
12.1.1 - Sales Representatives and Vendors
12.2 - Reporting Patient Condition
12.3.1 - Release of Patient Information to the News Media
12.3.2 - Release of Non-Patient Information to the News Media
12.3.3 - Release of Non-Medical Patient Information to Visitors and Callers
12.4 - Equipment Loans
12.5 - Affiliations With Other Institutions for Educational Purposes
12.6.1 - Clinical Access for External Agencies for the Purpose of Discharge Planning
12.6.2 - Clinical Access for Utilization Reviewers Not Employed by SMH
12.7 - Shadowing and Short-Term Observational Educational Experiences
13. Staff
13.1 - Identification Badges
13.2 - Paging
13.3 - Volunteers - Friends of SMH
13.4 - Parking
13.5 - Employee Canvassing
13.6 - Employee and Medical Staff Right to Non-Participation in Specific Health Care or Research Activities
13.7 - Training in Cardiopulmonary Resuscitation
13.8 - Contraband - Search and Confiscation
13.9 - Gifts/Gratuities
13.9.1 - Patient Referrals and Professional Courtesy: Legal Restrictions
13.10 - Incident Reports - Employees and Volunteers
13.11 - Chemical Hazard Communication
13.12 - Pre-Placement Drug and Alcohol Testing
14. Professional (Non-Physician) Practice Privileges
14.3 - Nurse Midwives
14.4 - Certified Registered Nurse Anesthetists
14.8 - Social Workers Not Employed by SMH
14.9 - Registered Physician Assistants
14.10 - Credentialing Health Care Workers Not Employed by SMH
14.11 - Privileging Practitioners Other than Physicians and Dentists
14.12 - Clinical Laser Privileges
15. Clinical Practice and Procedures
15.1 - Privileging in Carotid Artery Stent Implantation
15.2 - Clinical Laser Safety Policy
