OCTOBER 13,2005 POLICY AND PROCEDURE NURSING ADMINISTRATION
POLICY TITLE  POLICY NO. Effective Date (original) Last Review Date Last Revision Date Approval Date Approving Body Last Authority Plan of Action Target Date
SECTION I  ORGANIZATION FUNCTIONS  
Nursing Administration  
Budgeting: Calculating FTEs Sec. I  6301A-1 9/1/1997 6/1/2003 4/1/2003 Nursing Management Committee
Nursing Leadership Sec. I  6301A-2 12/1/1985 6/1/2003 4/1/2003 4/1/2003 Nursing Management Committee
Organizational Chart Sec. I  6301A-3 no actual policy statement in binder---only a chart is in existence
Patient Classification Sec. I  6301A-4 12/1/1985 6/1/2003 4/1/2003 Nursing Management Committee
Unit Patient Classification Sec. I  6301A-5 12/1/1985 4/1/2003 4/1/2003 4/1/2003 Nursing Management Committee
24 hour ward reports Sec. I  6301A-6 12/1/1985 6/1/2003 11/1/1999 12/1/1999  
 
Standards of Nursing Practice  
Nursing Practice and Patient Care Standards Sec. I  6301B-1 4/1/1999 6/1/2003 2/5/1999 10/1/2002 Nursing Management Committee
Standard of Nursing Practice Sec. I  6301B-2 12/1/1985 6/1/2003 10/1/2002 10/1/2002  
Reporting of License to Practice Nursing Sec. I  6301B-3 6/1/1988 6/1/2003 6/1/2003  
 
Performance Improvement(PI/QI) Plan Sec. I  6301C 10/1/2001 6/1/2003 9/10/2001 9/17/2001 Quality Management Committee
 
Management of Human Resources  
Competency Requirements Sec. I  6301D-1 12/1/1984 6/1/2003 4/31/01 10/1/1994 Nursing Management Committee
  11/1/1994 Executive Management Committee
Employee Dress and Personal Appearance Sec. I  6301D-2 12/1/1985 6/1/2003 12/1/2001  
Floating Of Nursing Personnel Sec. I  6301D-3 12/1/1985 6/1/2003 4/1/1999 3/1/1999 Nursing Management Committee
Nursing Absentee Sec. I  6301D-4 12/1/1985 3/1/2000 3/1/2000 3/1/2000 Nursing Management Committee
Nursing Staff Rights Sec. I  6301D-5 11/1/1999 6/1/2003 11/1/1999 11/1/1999 Nursing Management Committee
GMHA Volunteer Services in Nursing Sec. I  6301D-6 3/1/1990 6/1/2003 12/1/2002   Nursing Management Committee
Pay Differential Categories-Overtime/on-call/call-back pay Sec. I  6301D-7 10/27/1992 6/1/2003 9/1/1999 8/11/1999 Executive Management Committee
  9/1/1999 Board of Trustees
 
Job Sepcifications  
Cardiac Monitor Technician Sec. I  6301D-7a
Emergency Room Technician Sec. I  6301D-7b
Hemodialysis Technician Sec. I  6301D-7c
Hospital Licensed Practical Nurse I Sec. I  6301D-7d
Hospital Licensed Practical Nurse II Sec. I  6301D-7e
Hospital Nursing Supervisor I Sec. I  6301D-7f
Hospital Nursing Supervisor II Sec. I  6301D-7g
Medical Equipment Technician Sec. I  6301D-7h
Nurse Aide I Sec. I  6301D-7i
Nurse Aide II Sec. I  6301D-7j
Nursing Services Administrator Sec. I  6301D-7k
Nursing Services Assistant Administrator Sec. I  6301D-7l
Obstetric Technician Sec. I  6301D-7m
Operating Room Technician Sec. I  6301D-7n
Patient Courier Sec. I  6301D-7o
Staff Nurse I Sec. I  6301D-7p
Staff Nurse II Sec. I  6301D-7q
Ward Clerk Sec. I  6301D-7r
Hospital Nursing Unit Supervisor Sec. I  6301D-7s **none listed in black binder    
 
POLICY TITLE  POLICY NO. Effective Date (original) Last Review Date Last Revision Date Approval Date Approving Body Last Authority Plan of Action Target Date
Management of Information/Documentation  
Automated Documentation Sec. I  6301E-1 12/1/1999 6/1/2003 12/1/1999 12/1/2003  
Completion of Certification of Death Sec. I  6301E-2      
Discharge of Patient from unit Sec. I  6301E-3 12/1/1985 6/1/2003 12/1/1988  
Maintaining Medical Record Sec. I  6301E-4 12/1/1985 6/1/2003 6/1/1988 10/1/2002  
Nursing Documentation in the Medical Record Sec. I  6301E-5 12/1/1985 6/1/2003 12/1/2000  
Patient Activity Sec. I  6301E-6 12/1/1985 6/1/2003 8/2/1988  
Patient Care Assignments Sec. I  6301E-7 12/1/1985 6/1/2003 5/31/1988 10/1/2002  
Patient Checklist:  Patient Admission Sec. I  6301E-8 12/1/1985 6/1/2003 6/1/2003  
Patient Identification Sec. I  6301E-9 7/28/1992 6/1/2003 3/1/1993 3/27/1993 Executive Management Committee
Physician Orders & Written, Verbal, & Telephone Orders Sec. I  6301E-10 12/1/1992 6/1/2003 5/31/1988  
Standard Care Plans Sec. I  6301E-11 12/1/1985 5/1/1989   6/1/1989  
Transcribing Physician Orders Sec. I  6301E-12 12/1/1992 6/1/2003 12/1/1999  
Nurses Notes Sec. I  6301E-13 **none listed in black binder      
Daily Floor Census Sec. I  6301E-14 **none listed in black binder      
Priciples of Charting Sec. I  6301E-15 **none listed in black binder      
POMR Reduction Program Sec. I  6301E-16 **none listed in black binder      
Procedure Checklist Sec. I  6301E-17 **none listed in black binder      
 
Mangement of the Environment of Care  
Basic Isolation Principles Sec. I  6301F-1 4/20/1992 9/1/2005   8/1/1996 Infection Control Committee/EMC
Checking of Emergency Equipment & Supplies Sec. I  6301F-2 7/1/1992 6/1/2003 3/1/2000 6/1/2003
Emergency Medicine Department Visitiation Sec. I  6301F-4 9/14/1999 6/1/2003 12/1/1999 9/14/1999 Executive Management Committee
Fall Prone Prevention Sec. I  6301F-5 12/1/1999 6/1/2003 6/1/1999 6/18/1999 Nursing Management Committee
Food Policy Sec. I  6301F-6 8/10/1988 6/1/2003 9/1/1992 9/29/1992 Executive Management Committee
  1/22/1993 Infection Control Committee
Handling of Spills of Antineoplastic Drugs Sec. I  6301F-7 10/1/1997 10/1/1997  
Jail Custody Patients Sec. I  6301F-8 10/1/1999 6/1/2003 2/1/1999 2/1/1999  
Safety for Patients Receiving Radioactive Materials Sec. I  6301F-9 12/1/1985 6/1/2003 8/1/1988 12/1/2002  
Safety Guidelines for Patient Care Census Sec. I  6301F-10 12/1/1985 6/1/2003 3/1/2000 6/1/2003  
Administration of IV  Sec. I  6301F-11      
Universal Precautions Sec. I  6301F-12      
Visiting Policy Sec. I  6301F-13 10/1/1999 6/1/2003 6/1/2003 7/11/2001 Board of Trustees
Maintenance of Cardiac Arrest carts Sec. I  6301F-14 **none listed in black binder      
Isolation Sec. I  6301F-15 **none listed in black binder      
 
POLICY TITLE  POLICY NO. Effective Date (original) Last Review Date Last Revision Date Approval Date Approving Body Last Authority Plan of Action Target Date
SECTION II  PATIENT CARE FUNCTIONS  
Patient Rights & Organization Ethics  
Advance Directives Sec. II  6301A-1
Do Not Resuscitate (DNR) Sec. II  6301A-2
Emotional & Spiritual Sec. II  6301A-3
Ethical Issues/Dilemma Process Sec. II  6301A-4
Incidence Report Summary Sec. II  6301A-5
Infant Security Sec. II  6301A-6
Informed Consent Sec. II  6301A-7
Mangement of Emotionally/Mentally Il Sec. II  6301A-8
Organ & Tissue Donation/Transplantation Sec. II  6301A-9
Patient Care Rights Sec. II  6301A-10
Patient Rights for Children/Adolescent Sec. II  6301A-11
Patient Valuables Sec. II  6301A-12
Patient/SNU Resident Abuse & Neglect Sec. II  6301A-13
Release of Information Sec. II  6301A-14
Patient Rights&Organization ethics Sec. II  6301A-15 **none listed in black binder    
Confidentiality of Patient Info Sec. II  6301A-16 **none listed in black binder    
Occurrence Summary Report Sec. II  6301A-17 **none listed in black binder    
 
ASSESSMENT OF PATIENT  
Admission Assessment Sec. II  6301B-1
Assessment of Alcohol/Drug Dependencies Sec. II  6301B-2
Assessment of Victims Possible Aduse or Neglect Sec. II  6301B-3
Initial Assessment/Discharge Planning/Reassessment Sec. II  6301B-4
Pre-Anesthesia Assessment Sec. II  6301B-5
 
CARE OF PATIENT  
Adverse Drug Interaction/Definition (Nursing & Pharmacy) Sec. II  6301C-1
Automatac Stop Order Sec. II  6301C-2
Bedside Medications Sec. II  6301C-3
Code 72 Duties and Responsibilities Sec. II  6301C-4
Disposition of Controlled substances Sec. II  6301C-5
Drug & Food Interaction Sec. II  6301C-6
IVTherapy Administration Sec. II  6301C-7
Medication Administration Sec. II  6301C-8
Medication Administration Times Sec. II  6301C-9
Medication Ordered STAT Sec. II  6301C-10
Multidisiplinary Team Conference Sec. II  6301C-11
Pain Management Sec. II  6301C-12
Planning of Patient Care Sec. II  6301C-13
POM- Patient's Own Medication Sec. II  6301C-14
Pressure Sore/Wound Care Management Sec. II  6301C-15
Restraints Sec. II  6301C-16
Unit Stock Medications Sec. II  6301C-17
Unit Dose System Sec. II  6301C-18
Dispensing Medications after Pharmacy hours Sec. II  6301C-19 **none listed in black binder    
 
POLICY TITLE  POLICY NO. Effective Date (original) Last Review Date Last Revision Date Approval Date Approving Body Last Authority Plan of Action Target Date
PATIENT & FAMILY EDUCATION  
Patient Education Sec. II  6301D-1
 
CONTINUUM OF CARE  
Admission of Patients from Admitting Office and Emergency Department Sec. II  6301E-1
Alert Signs Sec. II  6301E-2
Autopsy Sec. II  6301E-3
Care of the Dying Patient Sec. II  6301E-4
Pronouncement of Death Sec. II  6301E-5
Chief Medical Examiner/Reportable deaths Sec. II  6301E-6
Determination of Death Sec. II  6301E-7
Direct Admission Policy Sec. II  6301E-8
Patient Discharge Planning Sec. II  6301E-9
Delivery of Flowers for a Patient Sec. II  6301E-10
Home Health Care Services Referral Sec. II  6301E-11
Stretcher Van Non-Emergency Transport Services Sec. II  6301E-12
Referral for Homebound Tutoring Sec. II  6301E-13
Admission of Newborns from Birthing center Sec. II  6301E-14
Transfers of Patient Intra-Unit and/or from ER Department Sec. II  6301E-15
Transfer of Patients to SNU Sec. II  6301E-16
Transfers within Patient Care Units  Sec. II  6301E-17
Transfer of Patient to Isolation Room Sec. II  6301E-18
Transporting of Body to Viewing Room Sec. II  6301E-19
Care of Body After Death Sec. II  6301E-20