FQHC Polices, Procedures & Documentation
Table of Contents
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Personnel Policies & Procedures (71 Policies in 4 Sections)
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General Employment (29 Policies)
1A - Employment Standards 2A - Job Classification 3A - Position Descriptions 4A - Orientation of New Employees 5A - Standard Work Hours 6A - Employee Compensation 7A - Recruitment for Vacant Positions 8A - Employee Evaluations 9A - Competencies 10A – Lay-Offs 11A - Salary Information 12A - Grievance Procedures 13A – Probation 14A – Separation of Employment 15A – Temporary Privileges 16A – Credentialing 17A – Nepotism 19A – Tardiness 20A - Travel Expenses 21A - Personnel Records 23A – Disaster Privileges 24A – Students 25A – Basic Cardiac Life Support 26A – Office Environment Policy 27A – Time Reporting 28A – Reference Policy 29A – Signatory Authority 30A - Lockers 31A – Peer Review Policy |
Employment Benefits (18 Policies)
1B – Jury Duty 2B – Bereavement Leave 3B – Vacation Leave 4B – Sick Leave 5B – Provider Recruitment Incentive 6B – Holiday Leave 8B – Unpaid Leave 9B – Pregnancy, Childbirth and Related Medical Conditions Leave 10B – Family Medical Leave Act 11B – Continuing Education 12B – Tuition Reimbursement 13B – Insurance 14B – Retirement Benefits 15B – Employee Health Care Benefit 16B – Volunteer Leave 17B – Break Time For Nursing Mothers 18B - Overtime 20B – Workers Compensation |
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Employee Conduct (19 Policies)
1C – Conduct of Employees 2C – Confidential Information 3C – Conflict of Interest 4C – Cell Phones and Electronic Devices 5C – Use of organization Computer Systems 6C – Tobacco and Smoking Related Products 7C – Drug-Free Workplace 8C – Garnishments, Attachments, and Judgments 9C – Employee Identification Badges 10C – Public/Media Information 12C – Solicitation of Goods and Services 13C – Dress Code 14C – Transportation of Patients 15C – Use of organization Vehicles 16C – Harassment 17C – Disciplinary Action 18C – Focused Review 19C – Impaired or Dysfunctional Provider 20C - Social Networking Policy |
Safety Policies (5 Policies)
1D – Bomb Threat 2D – Inclement Weather 3D – Concealed Weapon 4D – Tornado Warning 5D – Fire Regulations |
Clinical (30 Policies)
*All Clinical (30 files)
1.Abuse/Neglect Management
2.Acquisition of Supplies and Medications
3.Aerosol Treatment
4.Application of Ice Pack
5.Crash Cart
6.Ear Irrigation
7.EKG
8.Emergency Action
9.Eye Examination
10.Fingersticks
11.Hearing Screen
12.Immunizations – Administration of
12A. Immunizations – Nurse Visit Administration of
12B. Immunizations – Provider Visit Administration of
13.Mantoux Skin Test
14.Medication Administration - Intramuscular
15.Medication Administration – Oral
16.Medication Administration – Subcutaneous
17.Medication Administration – Z-Track
18.Nurse Visits
19.Oxygen Therapy
20.Pain Management
21.Pap Smears – Preparation of
22.STD Cultures – Preparing
23.Specimen Collection – Occult Blood
24.Specimen Collection – Throat
25.Specimen Collection – Urine
26.Time Out Procedures
27.Vital Signs – Orthostatic
28.Provider Ordered – Patient Obtained Medication
29.Critical Value Notifications
*All Clinical (30 files)
1.Abuse/Neglect Management
2.Acquisition of Supplies and Medications
3.Aerosol Treatment
4.Application of Ice Pack
5.Crash Cart
6.Ear Irrigation
7.EKG
8.Emergency Action
9.Eye Examination
10.Fingersticks
11.Hearing Screen
12.Immunizations – Administration of
12A. Immunizations – Nurse Visit Administration of
12B. Immunizations – Provider Visit Administration of
13.Mantoux Skin Test
14.Medication Administration - Intramuscular
15.Medication Administration – Oral
16.Medication Administration – Subcutaneous
17.Medication Administration – Z-Track
18.Nurse Visits
19.Oxygen Therapy
20.Pain Management
21.Pap Smears – Preparation of
22.STD Cultures – Preparing
23.Specimen Collection – Occult Blood
24.Specimen Collection – Throat
25.Specimen Collection – Urine
26.Time Out Procedures
27.Vital Signs – Orthostatic
28.Provider Ordered – Patient Obtained Medication
29.Critical Value Notifications
Environment of Care (36 Policies)
*All Environment of Care (36 files)
Hazard Materials and Waste Management
1.Hazard Surveillance / Risk Assessment
2.Hazardous Materials & Waste Management Program
3.Infectious Hazards / Universal Precautions Education
4.Infectious Waste, Segregation, and Collection of
5.Infectious Waste, Shipping of
6.Infectious Waste Spills: Clean-Up
7.Personal Protective Equipment
8.Hazard Communication Plan
Safety Management Policy
1.Safety Management Program
Security Management Policy
Utilities Management Program Policy
Equipment Management Policy
Emergency Preparedness Policy
Life Safety Policy
Infection Control Policy
*All Environment of Care (36 files)
Hazard Materials and Waste Management
1.Hazard Surveillance / Risk Assessment
2.Hazardous Materials & Waste Management Program
3.Infectious Hazards / Universal Precautions Education
4.Infectious Waste, Segregation, and Collection of
5.Infectious Waste, Shipping of
6.Infectious Waste Spills: Clean-Up
7.Personal Protective Equipment
8.Hazard Communication Plan
Safety Management Policy
1.Safety Management Program
Security Management Policy
- Protection Of Property
- Robbery
- Pharmacy Security
- Visitor/Student Badges
- Escalating Behavior
- Weapon Protocol
Utilities Management Program Policy
- Utilities Management Program
Equipment Management Policy
- Equipment Management Program
Emergency Preparedness Policy
- Emergency Preparedness
Life Safety Policy
- Fire Regulations
- Tornado Warning (Code Gray)
- Gas Leak (Code Green)
- Code STAT
- Sentinel Event
Infection Control Policy
- Communicable Disease, Reporting Of
- Contagious Diseases – Handing Of
- Post-Exposure Follow-Up
- Employee Exposure to Communicable Diseases
- Hand Hygiene
- Hepatitis B Vaccine Program
- Illness or Injury On-Duty
- Sterilization Techniques
- TB Patients – Care Of
- TB Testing & Follow-Up – Employee
- Influenza Vaccine Program
- Exposure Control Plan
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Dental (16 Policies)
*All Dental (16 files)
1.Back-Up testing of Sterilizers
2.Butane Burner and Torch
3.Dental Laundry
4.Dental Radiology Safety
5.Dental Instrument Sterilization
6.Hazardous Material Spill clean-up
7.Mercury Spill Clean-Up
8.Permissible Duties of Dental Hygienists and Dental Assistants
9.Radiation Quality Controls, Frequencies, and Responsible party
10.Radiation Exposure Monitoring
11.Radiation Quality Assurance and Control
12.Radiation Quality Control Test
13.Safe Operating Procedures for Radiation
14.NOMAD Portable X-Ray Safe Operating Procedures
15.Safe Operating Procedures for Radiation - Gendex Orthoralix 8500 DDE – Panoramic
16.Sterilizer Spore Testing
*All Dental (16 files)
1.Back-Up testing of Sterilizers
2.Butane Burner and Torch
3.Dental Laundry
4.Dental Radiology Safety
5.Dental Instrument Sterilization
6.Hazardous Material Spill clean-up
7.Mercury Spill Clean-Up
8.Permissible Duties of Dental Hygienists and Dental Assistants
9.Radiation Quality Controls, Frequencies, and Responsible party
10.Radiation Exposure Monitoring
11.Radiation Quality Assurance and Control
12.Radiation Quality Control Test
13.Safe Operating Procedures for Radiation
14.NOMAD Portable X-Ray Safe Operating Procedures
15.Safe Operating Procedures for Radiation - Gendex Orthoralix 8500 DDE – Panoramic
16.Sterilizer Spore Testing
Pharmacy (13 Policies, 1 additional file)
*All Pharmacy (14 Policies)
1. Pharmacy
2. Formulary
3. Medication Inventory
4. Medication Disposal
5. Patient Assistance Medication Pickup for Patients
6. Transcription for Medication Log out
7. Pharmaceutical Salesmen
8. Look Alike/Sound Like, High Alert & Hazardous Medication
9. Product Recall Notification
10. Vaccine Ordering, Storage & Handling
11. Medication handling during power outages
12. Vaccine related reactions - Reporting of
13. Vivitrol Program
Soundalike Listing
*All Pharmacy (14 Policies)
1. Pharmacy
2. Formulary
3. Medication Inventory
4. Medication Disposal
5. Patient Assistance Medication Pickup for Patients
6. Transcription for Medication Log out
7. Pharmaceutical Salesmen
8. Look Alike/Sound Like, High Alert & Hazardous Medication
9. Product Recall Notification
10. Vaccine Ordering, Storage & Handling
11. Medication handling during power outages
12. Vaccine related reactions - Reporting of
13. Vivitrol Program
Soundalike Listing
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Finance (40 Policies)
All Finance Polices (40 files)
General
1A - Fiscal Year Cycle
2A - External Reporting
3A - Internal Reporting, Monthly
4A - Monthly Bank Reconciliation
5A - Journal Entries
6A - Annual Audit
7A - Federal Draw Down
8A - Fixed Asset Inventory
9A - Capitalization/Depreciation
10A - Investment
11A - Electronic Funds Transfer (EFT)
12A - Bond Insurance
13A - Check Signatures
14A - Fiscal Record Retention
Payroll
1B - Payroll
2B - Payroll Overtime Payment
3B - Direct Deposit
4B - Payroll Statement Distribution
Accounts Payable
1C - Accounts Payable
2C - Expense Reimbursement
3C - Credit Cards
4C - Petty Cash
5C - Procurement
6C - Purchase Orders
7C - Receipt of Deliveries
Accounts Receivable
1D – Counterfeit Notes
2D – Encounter/Charge Passing Process
3D - Fee Schedule
4D - Account Adjustment
5D - Billing Cycles
6D - Collections
7D - Sliding Fee Scale
8D - Dental Service Treatment Estimates
9D - Cash Boxes
10D - A/R - Deposit of Receipts
11D - Refunding Overpayments and Incorrect Payments
12D - Returned Checks
13D - Medicare Credit Balance
14D - Credit/Debit Card Payment
15D - Check Payment
All Finance Polices (40 files)
General
1A - Fiscal Year Cycle
2A - External Reporting
3A - Internal Reporting, Monthly
4A - Monthly Bank Reconciliation
5A - Journal Entries
6A - Annual Audit
7A - Federal Draw Down
8A - Fixed Asset Inventory
9A - Capitalization/Depreciation
10A - Investment
11A - Electronic Funds Transfer (EFT)
12A - Bond Insurance
13A - Check Signatures
14A - Fiscal Record Retention
Payroll
1B - Payroll
2B - Payroll Overtime Payment
3B - Direct Deposit
4B - Payroll Statement Distribution
Accounts Payable
1C - Accounts Payable
2C - Expense Reimbursement
3C - Credit Cards
4C - Petty Cash
5C - Procurement
6C - Purchase Orders
7C - Receipt of Deliveries
Accounts Receivable
1D – Counterfeit Notes
2D – Encounter/Charge Passing Process
3D - Fee Schedule
4D - Account Adjustment
5D - Billing Cycles
6D - Collections
7D - Sliding Fee Scale
8D - Dental Service Treatment Estimates
9D - Cash Boxes
10D - A/R - Deposit of Receipts
11D - Refunding Overpayments and Incorrect Payments
12D - Returned Checks
13D - Medicare Credit Balance
14D - Credit/Debit Card Payment
15D - Check Payment
Information Technology - (11 Policies)
*Total Information Technology (IT) - (11 Files)
1 – Laptop Deployment
2 – Authenticate Electronic Personal Health Information / Record Revision
3 – Business Associates Agreements - Security Breaches
4 – System Unavailability Contingency Plan
5 – Emergency Access to EHR
6 – Information Technology (IT) Security
7 – Document Scanning/Indexing and Disposal
8 – Password Management
9 – Data Backups
10 – Social Networking
11 – Acceptable Use of IT Resources
*Total Information Technology (IT) - (11 Files)
1 – Laptop Deployment
2 – Authenticate Electronic Personal Health Information / Record Revision
3 – Business Associates Agreements - Security Breaches
4 – System Unavailability Contingency Plan
5 – Emergency Access to EHR
6 – Information Technology (IT) Security
7 – Document Scanning/Indexing and Disposal
8 – Password Management
9 – Data Backups
10 – Social Networking
11 – Acceptable Use of IT Resources
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Health Records (12 Files)
*All Health Records Policies (12 Files)
Health Records Policy 1 - Amendment of Health Records
Health Records Policy 2 - Consent
Health Records Policy 3 - Consent of Minor
Health Records Policy 4 - Patient Requests to Amend Health Record
Health Records Policy 5 - Patient Requests to Review Health Record
Health Records Policy 6 - Record Retention
Health Records Policy 7 - Release of Information
Health Records Policy 8 - Shredding
Health Records Policy 9 - Core Elements of an Authorization
Health Records Policy 10 - Privacy Breach Risk Assessment and Notification
Health Records Policy 11 - Invalid Authorizations
Health Records Policy 12 - Non-Residential Parents and Step-Parents
Emergency Preparedness Plan & Documentation (8 Files)
Emergency Preparedness Plan
Emergency Preparedness Plan Policy
Emergency Preparedness Plan Diagram
Emergency Preparedness Plan Organization Chart
Emergency Preparedness Plan Evaluation
Emergency Preparedness Plan Supplies & Equipment List
Emergency Preparedness Plan Leadership Job Descriptions
Emergency Preparedness Plan Public Information Officer JAC
Emergency Preparedness Plan Policy
Emergency Preparedness Plan Diagram
Emergency Preparedness Plan Organization Chart
Emergency Preparedness Plan Evaluation
Emergency Preparedness Plan Supplies & Equipment List
Emergency Preparedness Plan Leadership Job Descriptions
Emergency Preparedness Plan Public Information Officer JAC