Policies Manual

Table of Contents (Numerical)

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1	Table of Organization
2	Credentials for Staff
2.1	Maintenance of Departmental Personnel Files
3	Emergency Care Services at Mount Sinai - General Statement
3.2	Mission Statement
3.3	Vision Statement
4	Community Emergency Services - Relationship to ED
4.1	Relationship with Specialized Referral Center - EMS Advisory
4.2	Interhospital Transfer
4.3	Inter-Institutional Transfer of Patient
5	Emergency Preparedness Plan (EPP)
5.1	Emergency Response for Medical Center
5.2	Overcrowding and SURGE Management Plan
6	Employee Health Service Referrals
6.1	Toxicology Testing of Employees in the ED
7	Pre-Hospital Care from EMS and Others
7.1	EMS Exchange Requirements with Pre-Hospital Personnel
7.2	EMS Diversion Protocol (Diverson Form )
8	Return of a Discharged Patient by a Placement Facility
10	ED Referrals to OPD Clinics for Follow-up
10.1	Referral to Clinics for Initial Treatment
10.2	Telephone Advice in the ED
10.3	Telephone Tree for ED Registrars
11	Emergency Department Registration Log
12	Confidentiality of Patient Information
12.1	Acknowledgement of Receipt of Notice of Privacy Practices
12.2	Opting Out of the Directory
13	Medical Record and Reports
13.1	Medical Record Forms - Other
13.2	Maintenance of Medical Record
14	Consent, Adults
14.1	Consent, Minors
15	Health Care Proxy
16	DNR
17	Organ Donor Policy
18	Role of Emergency Department Attending
18.3	Job Description - House Staff
19	Job Description - Director, Emergency Department
19.1	Job Description - Administrator
19.2	Job Description - Clinical Nurse Manager
19.3	Job Description - ED Operations Coordinator
19.4	Job Description - Clinical Nurse
19.5	Job Description - Nurse Practitioner
19.6	Job Description - ED/EKG Technician
19.7	Job Description - Registrar
19.8	Job Description - Operations Coordinator
19.9	Job Description - Education Specialist
19.10	Job Description - Social Worker
19.11	Job Description - Patient Care Volunteer
19.12	Job Description - Charge Nurse
19.13	Job Description - Support Associate
19.14	Job Description - Clinical Coordinator
19.15	Job Description - Child Life Specialist
19.55	Job Description - Physician Assistant
20	Consults
20.2	Consults - General Surgery
20.3	Consults - Hand Injuries and Infections in Adults
20.4	Consults - OB/GYN
21	Psychiatric Evaluation in the Emergency Department
21.1	Psychiatric Patient Transport from Psych Clinic to ED
22	Radiology Services
23	Restraints and Locked Seclusion
23.2	Constant Observation of Patients
24	Laboratory Services
24.1	Laboratory Alert Values
24.2	Surgical Specimen Handling
24.3	Laboratory Services for Poisoning Overdose Ingestion
24.4	Gem 3000 Point of Care Blood Analysis
25	Location, Storage, and Procurement of Blood Supplies
25.1	Blood Bank Specimen Handling
25.2	Blood Sample Collection and Labeling
26	Social Work Services in the ED
26.1	Management of Suspected Child Abuse or Neglect
26.2	Elder/Institutional Abuse
26.3	Domestic Violence
26.4	Sexual Assault Protocol (Code 11)
26.5	ED Policy for Digital Photography
27	Patient Grievance Mechanism
28	Death Management Protocol
29	Interpreteam
30	Security-Police Intervention
31	Patient Property, Care of
32	Visiting Policy
33	Location, Storage and Procurement of Supplies in the ED
33.1	Equipment Maintenance
34	Admitting Policy
34.1	ED Attending Authority to Admit
34.2	Responsibility of ED Attending to Primary Attending
34.3	Admissions to Medicine
34.5	ICU Consults and Admissions
34.6	Admission of Hip Fracture Patients from the Emergency Department
34.7	Initial Care of Pregnant Patients Presenting to the Hospital
34.8	Admission of Patients with Diabetes Mellitus and Foot Ulceration or Infection
35	OR Availability
37.1	Management of Patients in the ED Holding Area
38	Standards for Nursing Care and Vital Signs
39	Triage and Retriage of AER and PER Patients
39.1	Triage of Psychiatric Emergency Patients
39.2	Triage of Direct Admission
39.3	Nursing Triage Assessment Guidelines
40	Guidelines for Nurse Initiated Laboratory Studies in Treatment Area
40.1	Guidelines for Nursing Orders on Admitted Patients
41	Medication Administration by ED Personnel
41.1	Dispensing Outpatient Medication to ED Patients
41.2	Obtaining Narcotics/Controlled Drugs from AER for Radiology
42	Standing Orders - Registered Nurses in AER
42.1	Standing Antipyretic Orders (PER)
42.2	PER Asthma Protocol and Standing Orders
42.3	AER Asthma Protocol and Standing Orders
43	Advanced Procedures by ED Registered Nurse
43.1	Standing Orders for Radiation Injury or Contamination
44	Immunizations-Pediatric Emergency Room
45	Procedures Which May Not Be Performed in the ED
46	Saline Locks
47	EKG Request and Performance of 12 Lead EKG's
47.1	EKG Transmission and Interpretation
48	Recalls and Reportable Diseases
48.1	Recall of Patients with Missed Fractures/X-Ray Interpretation
49	Alcoholism Protocol
50	Animal Bites and Wounds
50.1	Management of Non-Human Primate Bites or Mucosal Exposures
51	Burns - Initial Managment
52	Ischemic Chest Pain Protocol
52.1	Protocol for the Initial Evaluation and Management of Patients with Ischemic or Hemorrhagic Stroke
53	Hyperbaric Oxygen Treatment for Carbon Monoxide Poisoning
54	Conscious Sedation for AER
54.1	Conscious Sedation PER
55	Pharmacologic Adjuncts for Adult Endotracheal Intubation
56	Care of the Diabetic Patient
57	Care of Dialysis Patients in the ED
58	Endoscopy, Adult
58.1	Endoscopy in the PER
59	Management of Exposure to Blood/Body Fluids
59.1	Exposure to Hazardous Materials
60	Infection Control Guidelines
60.1	Infection Control - Tuberculosis Identification/Management
61.1	Management of Mother and Newborn in ED
61.2	Registration of Mother and Live Newborns in ED
61.3	Registration and Handling of Stillborns in the ED
61.4	Registration and Chart Completion for ED Patients
61.5	Medicare as a Secondary Payor
62	Ocular Emergencies
63	Management of Poisonings
64.1	Multiple Trauma - Management
67	Discharge of Patient from the ED
67.1	Emergency Discharge Policy
67.2	Discharge Against Medical Advice
67.3	Discharge of Undomiciled Patients

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