Sample Policies, Procedures and Forms

The following resources are provided as a service and are for information only. They should not be construed as a substitute for legal advice in any matter.  THIE encourages you to consult with legal counsel regarding the application of these resources. 

Accident Injury Report
Acknowledgement to Treat by PA
Acknowledgement to Treat by Midlevel Practitioner
Advance Directive Act Summary
Agenda format
Air Quality Symptoms
Anesthesia Equipment Daily PreOp checklist sample
Anesthesia Log for Routine Checks
ASHRM Disclosure of Medical Errors - Part I
ASHRM Disclosure of Medical Errors - Part II
ASHRM Disclosure of Medical Errors - Part III
Auto Usage Policy
Baby Moses Sign - English
Baby Moses Sign - Spanish
BNE Position on Delegation to P&EMT and Abandonment of Patients
Cellular Phone Prohibition Sign
Chain of Command
Chaperone Policy Sample #1
Chaperone Policy Sample #2
Competency - CNA
Competency - Pediatric Assessment
Competency - RN Orientation
Conflict of Interest for Board Sample 1
Conflict of Interest for Board Sample 2
Conscious Sedation Policy #1
Conscious Sedation Policy #2
Consent - Anesthesia by CRNA 1
Consent - Anesthesia by CRNA 2
Consent - Care of Newborn
Consent - Non-staff in OR
Consent - Temporary Absence
Consent - Visitor in OR
Credential File Checklist
Credential File Checklist #2
Credentialing during Disaster
Directive to Physician Form
Effect of Aging on Workers' Compensation Claims
Electronic Health Records - Part 1
Electronic Health Records - Part 2
Electrosurgery, AORN Position Paper
EMT's in ER Job Description
EMTALA
    20 Common Practices That Will Get On-Call Physicians Cited
    2004 EMTALA Complaint Surveyor Interpretive Guidelines
    Sample EMTALA indicators for quality program
    Mental Health Screening form
    OB Medical Screening Exam guidelines
    OB form
    Survey Guidelines for CAH/Swing Beds in CAH
    Sample EMTALA Transfer Indicators
Fall Prevention Policy
    Fall Data Collection Form
    Fall Intervention Checklist
    Fall QI Audit Form
    Fall Risk Assessment Form
Fee Waiver Letter (Sample)
Fire Extinguisher Procedure (RACE)
Fitness Center Waiver
Frequent Visitor Letter (Sample)
Helicopter Policy
High risk presentations to ED with protocols
Infant Abduction 1
Infant Abduction 2
Latex Allergy
Latex Allergy Signage
Locating Next-of-kin Seven Step Program
Medical Power of Attorney
Ostensible Agency White Paper
    Disclaimer for Doctor as Independent Contractor
    Disclaimer in Spanish for Doctor as Independent Contractor
Overview of 79th Legislative Session
Pandemic Flu Preparedness
Patient Grievance Protocol
Pediatric Admission History
Pediatric Assessment Flow Sheet
Pediatric Initial Assessment
Pediatric Pain Scale - Mankoski
Placental Exam
Placenta Exam Criteria
Preservation of Equipment Involved in Adverse Event
Prevention of Pressure Ulcers Policy
Preventive Maintenance Checklist for Patient Equipment
Prohibition of Concealed Handgun Signage
Quality Committee Statement of Confidentiality Form
Radiology Film Release Notification to Medical Records
Radiology Over-reads
Record Retention
Return to Work, Employee Health & HR Responsibilities
Return to Work Offer of Alternative Work
Return to Work Physician Referral
Return to Work Light Duty Positions
Return to Work Policy
Return to Work Process
Return to Work Responsibilities
Return to Work Sample Bona Fide Offer Letter
Safe Patient Handling/Movement Policy
Safety Rounds Checklist
Safety Statements for Job Descriptions
Sequestered Charts
Service Animals
Sexual Harassment 1
Sexual Harassment 2
Substance Abuse
Suicide Ongoing Assessment
Suicide Precautions
Telephone Advice - ER
Termination of physician-patient relationship
Wellness Center Waiver and Consent
Workplace Violence