Medical Staff Portal
Corporate Services

A-Z Policy Listing

Policy Title Policy # Date Effective Manual Resources / Keywords / Notes
Cleaning and Sanitizing Food Contact Surfaces 3.1.1 2015-04-23 NFS  
Employee Dress Code 1.3.0 2015-04-23 NFS  
Food Consumption 3.3.1 2014-11-18 NFS  
Food Tasting 5.2.9 2014-07-03 NFS  
Waste Removal 3.1.4 2014-07-03 NFS  
Dress Code 2016-06-28 EVS  
Cleaning Outcome Standard 2015-03-03 EVS  
Cleaning Frequency Standard 2017-10-24 EVS  
Patient Lift Equipment 2015-01-22 EVS  
Discharge and Transfer Cleaning - Isolation 2015-03-03 EVS  
Bed Cleaning (Discharge Transfer) 2015-07-07 EVS  
Bed Making (Discharge Transfer) 2015-07-07 EVS  
Patient Resident Washroom Cleaning 2015-07-07 EVS  
Occupied Patient Rooms (Isolation) 2016-06-29 EVS  
Occupied Patient Cubicle (Routine) 2015-08-04 EVS  
Whiteboard Cleaning 2016-06-28 EVS  
Linen Cubicle Curtain Changing 2016-06-28 EVS  
Discharge and Transfer Cleaning 2015-03-03 EVS  
Blood and Body Fluids 2017-07-13 EVS  
Commodes 2013-10-16 EVS  
Sinks 2013-10-16 EVS  
Toilets, Urinals, Hoppers 2013-10-16 EVS  
Patient Room Tubs and Showers 2014-11-07 EVS  
Patient Resident Nourishment Centre 2014-05-06 EVS  
Soiled Clean Utility Rooms 2014-07-14 EVS  
Staff Lounges 2014-11-07 EVS  
Locker Rooms 2016-06-28 EVS  
Offices, File and Storage Rooms, Workstations, Classrooms and Conference Rooms 2016-06-28 EVS  
Dispenser Cleaning and Replenishment 2016-06-29 EVS  
Window, Drapery, Blind Cleaning 2014-05-06 EVS  
Corridors and Hallways 2017-07-13 EVS  
Entrances and Lobbies 2013-10-16 EVS  
Stairs and Landings 2013-10-16 EVS  
Public Washrooms 2014-11-07 EVS  
Wall Washing 2015-03-03 EVS  
Elevators 2015-07-15 EVS  
Dry Mopping 2017-07-13 EVS  
Flood Pick-up and Clean-up 2014-05-06 EVS  
Wet Vacuum Pick-up 2014-05-06 EVS  
High Dusting 2014-11-07 EVS  
General Waste Sorting, Handling and Disposal - Dec. 4, 2017
Anatomical Waste Sorting, Handling and Disposal - Dec. 5, 2017
Biomedical Waste Handling and Disposal - Nov. 30, 2017
Confidential Material Sorting, Handling and Disposal - Nov. 30, 2017
Cytotoxic Waste Sorting, Handling and Disposal - Dec. 20, 2017
Hazardous Chemical Waste Sorting, Handling and Disposal - Nov. 30, 2017
Medication / Pharmaceutical Waste Sorting, Handling and Disposal -, Nov. 6, 2017
Inspection Checklist
Inspection Checklist User Guide
Inspection Process


Pharmacy - Sterile Compounding Areas 2016-06-28 EVS  
Pharmacy - Non-Sterile Areas 2016-06-28 EVS  
Laboratory Cleaning 2016-06-28 EVS  
Personal Protective Equipment 3.2.10 2014-11-07 EVS  
Post HAZMAT - CBRN Cleaning 2015-03-03 EVS  
Single Use Surgical Textiles 2016-06-29 EVS  
Corporate Vehicle Policy I-55 2012-11-01 Corporate  
Electrical Equipment I-60 2015-05-08 Corporate  
Ethical Decision-making Framework I-30 2014-01-17 Corporate  
Identification Cards I-35 2014-11-07 Corporate  
Key and Lock Control I-65 2015-05-08 Corporate  
Medical Emergency Response Policy I-45 2015-03-06 Corporate medical emergencies; visitors
Research III-10 2015-09-11 Corporate  
Spiritual / Religious Ceremonies I-50 2016-04-08 Corporate Sweetgrass, Chapel services,
Abuse of Patients, Residents or Clients III-75 2013-01-14 Corporate  
Building a Just Culture III-35 2011-10-01 Corporate  
Conflict of Interest III-15 2016-05-06 Corporate Personnel Declaration Form June 2016
CliC online module on Compliance and Business Ethics
Contracts III-60 2015-03-06 Corporate Contract Checklist, Outsourcing Services Framework Document    
Disclosure of Adverse Events, Close Calls and Hazards III-40 2011-10-01 Corporate  
Disclosure of Wrongdoings and Protection of Persons who Disclose Wrongdoings III-70 2014-08-15 Corporate Disclosure of Wrongdoings Report
Whistleblower Procedures Checklist
Enterprise Risk Management III-90 2014-07-11 Corporate Framework
ERM Risk Impact Categories
Family Paid Private Duty Care Providers and Companions III-80 2013-03-11 Corporate Authorization Form
Intellectual Property III-50 2011-12-05 Corporate original works, inventions, patents
Media Relations III-85 2013-07-15 Corporate Information Releases
Patient Concerns Resolution Process III-95 2014-10-10 Corporate Complaints, <"ie/Page510.aspx" target="_blank">Resource Page
Records Management III-55 2012-10-15 Corpoate Record Disposition, Record Retention, Legal Hold
Relationships with Industry III-20 2016-05-06 Corporate Conflict of Interest
CliC online module on Compliance and Business Ethics
Reporting / Investigating Legal Actions and Potential Legal Actions III-5 2016-02-05 Corporate  
Responding to Adverse Events, Close Calls and Hazards III-45 2013-01-14 Corporate Reporting Adverse Events
<"frm-09570.doc ">Fillable Product Feedback Form (use for reporting product defects, failures and incidents)
Adverse Event Guides 
Social Media II-155 2014-07-11 Corporate  
Accounts Receivable Management IV-45 2016-05-25 Corporate  
Delegation of Authority for Financial Commitments IV-15 2012-01-03 Corporate

Appendix A - Signing Authority Levels
Signing Authorities Form

Financial Assistance to Uninsured Patients IV-10 2014-01-17 Corporate  
Payroll Practices IV-40 2016-01-08 Corporate e-People
Preferred Accommodation IV-30 2013-09-13 Corporate single rooms
Travel, Hospitality and Working Session Expenses - Approval, Reimbursement and Disclosure IV-5 2016-10-01  Corporate Conference fees, mileage, insurance
<"Page3233.aspx">Finance Forms
Privacy Accountability X-5 2014-07-11 Corporate

<"Page552.aspx">Information and Privacy Resource Page

Confidentiality Agreement and Privacy Training X-10 2014-07-11 Corporate  
Access to Personal or Health Information by Individuals X-15 2016-07-11 Corporate  
Collection and Use of Personal or Health Information X-20 2014-07-11 Corporate  
Contractor Requirements for Security of Information and IT Resources X-25 2014-07-11 Corporate  
Correction of Personal or Health Information X-30 2014-07-11 Corporate  
Disclosure of Personal or Health Information to Third Parties X-35 2014-07-11 Corporate  
Information Privacy Breach or Information System Security Incident Response X-40 2014-07-11 Corporate  
Information Security Classification X-45 2014-07-11 Corporate  
Information Technology Acceptable Use and Safeguards X-50 2014-07-11 Corporate  
Privacy Impact Assessments and Monitoring X-55 2014-07-11 Corporate  
Transmission of Personal or Health Information X-60 2014-07-11 Corporate  
Transportation of Personal or Health Information X-65 2014-07-11 Corporate  
Application of Human Resources Policies and Procedures     II-1 2017-06-26 Corporate  
CPR Certification and Re-certification II-5 2016-11-04 Corporate  
Change in Employee Personal Information II-10 2013-11-08 Corporate  
Compensation for Out of Scope Employees II-15 2018-03-01 Corporate  
Criminal Records Check II-16 2017-09-27 Corporate Resources:
Discipline and Termination II-20 2013-11-08 Corporate  
Dress Code     II-25 2017-06-20 Corporate Scents, perfume
Employment Contract Relationships II-30 2017-08-18 Corporate  
Exit Interviews II-35 2013-11-08 Corporate  
Group Benefits II-40 2018-01-01 Corporate  
Human Resources Employee Files II-52 2013-11-08 Corporate  
International Recruitment II-150 2013-12-06 Corporate  
Job Evaluation and Titling Out of Scope Employees II-50 2017-08-18 Corporate  
Job Shadow II-53 2012-11-01 Corporate

Job Shadow Application - Appendix B
Job Shadow Responsibilities - Appendix C
Job Shadow Confidentiality - Appendix D

Leaves of Absence    II-55 2018-02-18 Corporate Miscarriage, Stillbirth Guidelines
Bereavement, Maternity Leave, Adoption Leave, Parental Leave, Jury Duty, Compassionate Care Leave, Paid Leaves of Absence, Military, Leave for Public Office, Education Leave, Terminal Care, Domestic Violence Leave, Citizenship Ceremony Leave, Critical Illness Leave, Death or Disappearance of a Child Leave, 
Local Authorities Pension Plan     II-60 2017-06-20 Corporate  
Named Holiday and Floater Days II-70 2018-01-01 Corporate Stat holidays, Statutory holidays
Performance Development     II-75 2017-06-20 Corporate Performance Reviews
Personal Leave Days - Out of Scope II-80 2018-01-01 Corporate HEX Days
Professional Registrations II-85 2015-05-08 Corporate  
Recognition of Long Service and Retirement II-90 2016-12-09 Corporate  
Recruitment (Posting, Selection and Hiring) II-95 2013-11-08 Corporate  
Recruitment Travel and Relocation Expenses II-100 2010-07-05 Corporate  
Sick Leave and Salary Continuation II-105 2018-01-01 Corporate  
Student Clinical Placements II-115 2016-04-08 Corporate  
Termination of Employment or Department Transfer II-118 2013-03-11 Corporate  
Use of Cell Phones and Other Wireless Devices While Driving II-120 2013-11-08 Corporate  
Vacation Accrual and Utilization II-125 2016-08-12 Corporate  
Volunteer Services Policy II-160 2014-08-15 Corporate Volunteer Program Standards of Practice Guidelines (May 2014)
Health and Safety Policy II-130 2016-12-09 Corporate

Occupational Health & Safety Page

bE LITE Safe Patient/Resident Handling II-170 2015-01-09 Corporate Musculoskeletal Injury, Back Injury
Critical Incident Stress Management II-18 2016-12-09 Corporate CISM
Influenza Immunization and Outbreak Management II-165 2014-10-10 Corporate <"ie/Page475.aspx" target="_blank">Resource Page
Reporting of Work-related Incidents, Injuries, Illness II-135 2016-12-09 Corporate  
Working Alone II-140 2015-10-09 Corporate  
Workplace Abuse and Harassment      II-145 2017-09-15 Corporate Resource:  Abuse Investigation Checklist 
Standardized Assessment, Care Planning and Care Conferences VII-C-10 2018-04-06 Corporate

Continuing Care 

Choking Prevention and Management VII-C-30 2016-08-12 Corporate Continuing Care
Choking Prevention and Management PowerPoint August 2016
Cytotoxic Medications VII-C-25 2014-10-10 Corporate Continuing Care
Palliative Care Pathways VII-C-20 2014-10-10 Corporate Continuing Care
Palliative Care Pathway - 8 Hour Shifts
Palliative Care Pathway - 12 Hour Shifts
Hospice Palliative Care Education Resources
Family Information Sheet
Staff Guidelines
Resident Bathing and Safe Water Temperature VII-C-15 2017-08-18 Corporate Continuing Care 
Resource Documents:
Infection Prevention and Control VI-5 2016-08-12 Corporate

<"Page172.aspx" target="_blank">Infection Prevention and Control Resource Page

Animal Visitation VI-25 2016-08-12 Corporate Pets, dogs, cats
Clostridium difficile Infection (CDI) VI-8 2016-09-16 Corporate CDI
Hand Hygiene     VI-10 2017-08-18 Corporate fingernails, gel nails, jewelry
Immediate Use Steam (Flash) Sterilization VI-45 2015-04-10 Corporate  
Management of Patients with Suspected and/or Confirmed Pulmonary or Laryngeal Tuberculosis VI-32 2016-05-06 Corporate TB
Methicillin-Resistant Staphylococcus Aureus VI-15 2016-08-12 Corporate MRSA
Multi-drug Resistant (MDR) Gram-Negative Organisms VI-20 2016-03-11 Corporate ESBL, MDRO, AmpC, CRO, CRE, KPC, NDM, VIM
Single-use Medical Devices VI-30 2014-09-12 Corporate  
Therapy / Recreational Aid and Toy Cleaning VI-35 2018-03-09 Corporate Toys, therapy aid, recreational aid
Vancomycin-Resistant Enterococcus VI-40 2016-08-12 Corporate VRE

Home Parenteral Therapy Program - Prevention and Treatment of Upper Extremity Catheter-Related Thrombosis (Edmonton Zone)

IV Vascular Access Device - Quick Reference Protocol   2017-08-17 Corporate CVC, PICC, IVAD
Care and Removal of Central Vascular Access Devices - Non-Tunnelled VII-B-380 2017-09-15 Corporate CVC
Care and Removal of Central Vascular Access Devices - Tunnelled VII-B-385 2017-09-15 Corporate CVC
Care and Removal of Peripherally Inserted Central Catheters (PICC) VII-B-305 2017-09-15 Corporate Resources:
Central Venous Catheter - Blood Collection VII-B-300 2017-09-15 Corporate CVC
Learning Module available on CLiC
Order of Draw Poster - Nov. 9, 2017
Vacutainer Posters
Scrub the Hub Video
Prevent Central Line Infections, "Getting Started Kit", from the Patient Safety Institute, dated June 2012
Hypodermoclysis (HDC) Administration VII-B-315 2017-09-15 Corporate  
Implanted Venous Access Device (IVAD) - Adult VII-B-320 2017-09-15 Corporate Resources:
Insertion of Peripherally Inserted Central Catheters   2016-04-06 Parental Therapy Program PICC Insertion
Maintenance of IV / Hypodermoclysis Equipment          VII-B-330 2017-09-15 Corporate change times for tubing, dressings, caps, administration sets,
Occlusion Management of Central Vascular Access Devices VII-B-335 2017-09-15 Corporate CVC
Restoring Patency of Vascular Access Devices     
PowerPoint Learning Module
Performance Checklists and Tests   
Peripheral IV Catheter          VII-B-390 2017-09-15 Corporate Manufacturer product information available through Google search. For example, check YouTube for videos on application and removal of:
- 3M Tegaderm Transparent Film
- ProtectIV Safety IV Catheter
- Accuvance Safety IV Catheter
- BD Insyte Autoguard Shielded IV Catheters
- BD Nexiva
- Tegaderm IV Securement Dressing for Nexiva Catheters
- BD DecisIV Educational Brochure - Complications of Peripheral IV Access
- BD DecisIV Educational Brochure - Phlebitis - Inflammation of the Intimal Lining of the Vein
- Layers of the Vein
- StatLock IV Premium Stabilization Device
Automated Dispensing Machines (ADM, Pyxis)        VII-A-55 2016-10-08 Corporate  
Bridge Supply of Medications for Discharged Patients VII-B-120 2015-05-05 Corporate FAQ     
Ordering Info for Preprinted Medication Dispensing Labels and PPCOs    
Clarification, Refusal to Implement Orders VII-A-5 2014-07-11 Corporate  
Controlled Substances      VII-B-245 2015-12-11 Corporate Memo
Fact Sheet (Nov. 2015)
Loss or Theft Report Form     
Discrepancy Reporting Form
Patient Specific Narcotic & Controlled Drug Record
High Alert Medications (HAM)
  • Management of Concentrated Electrolytes
  • Management of Heparin Products
  • Management of Restricted Narcotics
VII-A-30  2017-12-07 Corporate High Alert Medication List Poster     
Medication Administration  VII-A-50 2015-03-06 Corporate  
Medication Formulary VII-B-345 2014-02-07 Corporate Medication classification, approval, procurement
Medication Orders VII-B-125 2012-03-20 Corporate includes verbal orders, telephone orders
Frequently Asked Questions
Medication Reconciliation at Key Transitions of Care VII-B-235 2014-10-10 Corporate <"ie/Page451.aspx" target="_blank">Resource Page
Pre-Printed Medication Order Sets (PMOS) VII-B-445 2018-02-09 Corporate Pre-Printed Patient Care Orders (PPCO)
<"Page2950.aspx">Resource Page
Pro Re Nata (PRN) Medication VII-B-40 2014-09-12 Corporate  
Prohibited Abbreviations, Symbols and Dose Designations VII-A-25 2017-03-10 Corporate Frequently Asked Questions
Restrictions on the Sale of Pharmaceuticals to External Entities III-30 2014-08-15 Corporate  
Standardized Medication Concentrations for Parenteral Administration VII-B-80 2016-07-08 Corporate <"ie/Page1420.aspx" target="_blank">Resource page on CompassionNet
Tall Man Lettering VII-B-340 2017-12-08 Corporate

Medication Labelling
Tall Man Lettering List Nov. 2017

Vaccine Storage and Handling VII-A-60 2016-09-16 Corporate  
Early Induction of Labor VII-B-10 2017-08-18 Corporate  
Emergency Contraception in Cases of Sexual Assault VII-B-15 2014-03-07 Corporate  
Restraints: Physical Restraints VII-B-85 2011-09-21 Corporate  
Venous Thromboembolism Prophylaxis VII-B-370 2015-01-09 Corporate Resource: Guidelines for the Use of Sequential Compression Devices
Accommodating Special Requests VII-B-5 2014-01-17 Corporate  
Advance Care Planning: Goals of Care Designation VII-B-350 2017-11-10 Corporate <"ie/Page782.aspx" target="_blank">Resource page on CompassionNet
Allergy and Adverse Reaction - Communication and Documentation VII-B-360 2014-10-01 Corporate Poster
Caution Record Form
Assessment of Decision-making Capacity VII-B-35 2017-11-10 Corporate  <"Page2954.aspx">Capacity Assessment Resource page on compassionNET 
Bladder Scanning Using Non-Ionizing Radiation      VII-B-425 2018-04-06 Corporate Resource:
Clinical Practice Textbooks VII-B-115 2015-04-10 Corporate Nursing Resources Textbooks
Communication of Critical Lab Results VII-B-450 2016-07-06 Corporate  
<"ie/Page433.aspx">Consent to Treatment     Corporate link includes Corporate Policy, Procedures and Other Resources (eg. forms, education toolkits, decision algorithms, links to external sites, etc.)
Spinal, or Suspected Spinal, Injury VII-B-150 2015-11-06 Corporate C-Spine policy/procedure
Logrolling Technique with C-Spine Precautions VII-B-155 2015-11-06 Corporate C-Spine policy/procedure
Logrolling Technique without C-Spine Precautions VII-B-160 2015-11-06 Corporate C-Spine policy/procedure
Application and Maintenance of Extrication Collar VII-B-165 2015-11-06 Corporate C-Spine policy/procedure
Philadelphia® Collar Care VII-B-170 2015-11-06 Corporate C-Spine policy/procedure
Surface to Surface Transfer VII-B-175 2015-11-06 Corporate C-Spine policy/procedure
General Care of the Patient VII-B-180 2014-06-06 Corporate C-Spine policy/procedure
Spinal Signs Measurement      VII-B-185 2014-06-06 Corporate C-Spine policy/procedure
Death VII-B-410 2017-12-08 Corporate Care of deceased
Ethics Framework for Long Term Medically Administered Nutrition VII-B-355 2014-07-11 Corporate

Tube Feed
Decision Making Guidelines
Patient and Family Guidelines

Falls Risk Management VII-B-435 2016-10-07 Corporate <"page3154.aspx">Resource Page
Family Presence During CPR VII-B-365 2015-01-09 Corporate Code blue, resuscitation
Full Scope of Practice VII-B-110 2018-05-11 Corporate  
Identification of Patient, Resident or Client Using Two Identifiers VII-B-25 2016-04-08 Corporate  
Interpretive Services VII-B-20 2018-05-11 Corporate <"Page215.aspx">Resource Page 
Latex Allergy Precautions VII-B-105 2017-08-18 Corporate  
Neurological Determination of Death VII-B-400 2015-08-07 Corporate Brain death, brain dead
Organ and Tissue Donations VII-B-415 2015-08-07 Corporate  
Oxygen Equipment Used by Patients/Residents/Clients VII-B-130 2012-05-15 Corporate  
Patient Request for Specific Health Care Provider VII-B-30 2016-02-05 Corporate  
Peritoneal (PleurX) Catheter - Drainage and Care of the Inpatient VII-B-90 2015-08-07 Corporate  
Personal Directives VII-B-405 2015-08-07 Corporate  
Pleural (PleurX) Catheter - Drainage and Care of the Inpatient VII-B-95 2015-08-07 Corporate  
Responding to Requests for Medical Assistance in Dying VII-B-440 2017-09-15 Corporate Physician Assisted Suicide, MAID - Medical Assistance in Dying
<"Page3039.aspx">Resource Page
Safe Surgery Checklist VII-B-240 2016-08-12 Corporate Link to Learning Videos
SSC PowerPoint
User Manual
Covenant Health Safe Surgery Checklist (with leads and responsibilities noted)
AHS Safe Surgery Checklist
Safe Surgery Checklist for C-Section
Safe Surgery Checklist for Opthalmology
Transfer of Patient/Resident Information and Accountability Policy VII-B-255 2013-06-10 Corporate Transfer of Accountability - Internal Transfer form (2015/07)
Sample Forms:
Labour & Delivery transfer to Post Partum
Labour & Delivery transfer to Antepartum
Transfusion of Blood Components and Products VII-B-395 2018-01-12 Corporate <"7723.asp" target="_blank">Guide to Blood Transfusion Manual
Provincial Transfusion Medicine Resource Website
Urinary Catheter Insertion with Lidocaine 2% Jelly VII-B-100 2015-08-07 Corporate Resource: Reducing Iatrogenic Urethral Injury & Urinary Tract Infections
Photograph of Admitted Mental Health Patients VII-B-420 2015-07-10 Corporate Mental Health Program
Shift Notification Process   2016-09-13 Camrose  
Avalanche Victim Resuscitation Checklist   2013-10-13 Banff  
Lost and Found 05:05 2015-10-01 Banff  
Surge Capacity Protocol ER-7290 2016-05-24 Camrose Emergency Department
Manual Cleaning of Instruments   2015-08-01 Camrose MDRD Department
Reprocessing of Reusable Critical Medical Devices   2015-08-15 Camrose MDRD Department
Surgical Instrument Cleaning   2015-08-01 Camrose MDRD Department
Transport and Distribution of Soiled and Sterilized Medical Devices Within the Facility   2015-08-01 Camrose MDRD Department
Discharge Profiles III-61 2010-10-18 Camrose Pharmacy
Medication Cart Security IV-54 2010-07-26 Camrose Pharmacy
Medication Time Schedule IV-50 2017-04-01 Camrose Pharmacy
Multidose Vials III-30 2013-10-25 Camrose Pharmacy
Single Patient Use Medications III-20 2008-12-31 Camrose Pharmacy
Stability of IV Irrigation Bags III-72 2010-07-26 Camrose Pharmacy
Stop Orders, Automatic IV-30 2013-03-25 Camrose Pharmacy

Admission Criteria to the Neonatal Nursery    

  2017-05-01 NICU  

Aerosol Therapy

  2013-12-01 NICU  
Antibiotic Resistant Organism (ARO) Screening   2015-10-01 NICU  

Assessment of the Newborn Infant

  2015-04-01 NICU  
Assisted Ventilation - Care of the Infant   2015-08-01 NICU  
Bilirubin     NICU Neonatal Jaundice, Treatment Threshold Graphs - May 2010
Hyperbilirubinemia less than 35 Weeks - Sept. 2015
Hyperbilirubinemia greater than 35 Weeks - Sept. 2015
Phototherapy - Aug. 2015
Universal Pre-Discharge TCB Screening for Term and Late Preterm Infants - July 2015
Bladder Catheterization   2015-05-01 NICU  
Bladder Tap Assisting   2015-08-01 NICU  
Transfusion of Blood Components and Products - Addendum to corporate policy   2015-08-01 NICU  

Blood and Fluid Warmer

  2015-09-01 NICU  

Blood Culture

  2015-03-01 NICU  
Blood Pressure Monitoring Arterial Lines   2015-05-01 NICU  
Blood Sampling - Assisting with Arterial Puncture   2015-11-01 NICU  
Blood Sampling Central Venous Lines   2015-05-01 NICU  
Blood Sampling Heelstick   2015-09-01 NICU  
Blood Sampling Venipuncture   2015-05-01 NICU  
Therapeutic Hypothermia Guideline (Body Cooling, TBC)   

Pre-Transport Therapeutic Hypothermia Guideline
  2017-07-01 NICU Resources:

Bottle Feeding

  2017-05-01 NICU  

Breast Milk / Human Milk
Donor Human Milk
Human Milk Misappropriation
IPC Guidelines for Handling of Expressed Breast Milk
Mother's Own Milk (MOM)   
Breast Feeding Policy (see Corporate Policy)

  2015-12-01 NICU  
Car Seat Position Evaluations   2014-10-01 NICU  
Cellular and Wireless Devices   2016-04-01 NICU  
Central Arterial / Venous Lines   2015-05-01 NICU  

Central Line Dressing

  2015-05-01 NICU  
Central Venous Catheter Insertion - Assisting   2015-05-01 NICU  
Central Venous Pressure Monitoring   2015-11-01 NICU  
Chest Drains   2017-07-01 NICU  


  2015-10-01 NICU  
Cord Care   2015-02-01 NICU  
Cranial Ultrasound Screen   2015-05-01 NICU  
Deceased - Care of   2015-10-01 NICU  
Defibrillation and Cardioversion (GNCH)   2015-05-01 NICU  
Defibrillation and Cardioversion (MCH)   2015-05-01 NICU  
DEHP Exposure   2015-05-01 NICU  
Delayed Cord Clamping in Preterm Infants Less Than 37 weeks   2015-02-01 NICU  

<"11463.asp">Developmental Care Guidelines 

  • NICU Development Care
  • NICU Environment - Lighting Control
  • NICU Environment - Noise Control
  • NICU Skin to Skin Care
  2017-04-27 NICU  
Diagnostic Imaging   2015-06-01 NICU  
Discharge from NICU   2015-09-01 NICU  
Early Onset Neonatal Sepsis (EONS)   2016-04-01 NICU  
Endotracheal Extubation   2016-07-01 NICU  
Endotracheal Intubation - Assisting   2015-09-01 NICU  
Endotracheal Suction (Inline)   2015-10-01 NICU  
Enteral Feeding Guidelines   2015-11-01 NICU  
Enterostomy Care   2016-06-01 NICU  
Enterostomy Refeeding   2016-06-01 NICU  
Exchange Transfusion   2013-03-01 NICU  
Extravasation   2016-07-01 NICU  

Eyes, Prophylactic Care of the Newborn Eyes Prophylaxis / Timing

  2016-07-01 NICU  
Falls Mitigation Strategy   2015-10-01 NICU  
Fluid Management   2015-07-01 NICU  
Frenotomy - Assisting   2015-12-01 NICU  
Gastric Gavage Feeding   2015-10-01 NICU  

Gastrostomy Tube Care and Feeds

  2015-10-01 NICU  
Glucose Screening   2017-05-01 NICU & Womens Health  
Hearing Loss Screen   2012-01-01 NICU  
Hepatitis B Prevention - Infants   2016-06-01 NICU  
Heparin Use: Recommendations   2015-10-01 NICU  
HIV Protocol - Regional Guidelines   2014-08-01 NICU  
INTERhospital Transfer   2015-04-01 NICU  
INTRAhospital Transfer   2015-04-01 NICU  
Intrapleural Aspiration - Assisting   2015-08-01 NICU  
Intravenous Lock   2015-09-01 NICU  
Intravenous Therapy   2015-04-01 NICU  
IVIG - Drug Monograph     NICU  
Jejunostomy Tube Care and Feeds   2015-10-01 NICU  
Care of Late Preterm Infant Guidelines   2017-03-17 NICU  
Line and Tubing Verification   2015-11-01 NICU  
Lumbar Pumcture - Assisting   2015-10-01 NICU  
Maxilene Cream and EMLA Cream Use   2016-07-01 NICU  
Neonatal and Infant Follow-up Clinic   2015-05-01 NICU  
Neonatal Abstinence Syndrome   2015-10-01 NICU  
<"9307.asp" target="_blank">Newborn Metabolic Screen Policy Suite - including Blood Spot Screening @ <"9307.asp">     NICU  
Non-Invasive Monitoring   2015-10-01 NICU  

Oral Immune Therapy

  2013-12-01 NICU  
Oxygen Delivery   2015-10-01 NICU  

Pain Assessment and Management

  2015-10-01 NICU  
Parenteral Nutrition / TPN   2015-11-01 NICU  
Peripheral Arterial Line Insertion and Removal - Assisting   2015-10-01 NICU  
Posting of Inpatient Names   2015-04-01 NICU  
Pre-Term Infant (less than 37 weeks gestational age) NICU Monitoring Guidelines   2014-01-01 NICU  


  2015-09-01 NICU  


  2015-10-01 NICU  

Resuscitation in the Delivery Room 
Grey Nuns - July 2015
Misericordia - January 2018
Documentation of NeoNatal Resuscitation Occuring at Birth - July 2015

  2015-07-01 NICU &
Womens Health
Resource Documents:
Retinopathy of Prematurity   2014-10-01 NICU  
RSV Prevention Program     NICU  
<"9537.asp" target="_blank">Safe Infant Sleep - Resource Page     NICU  
Safety Guidelines   2015-10-01 NICU Tub Bath Safety - October 2013
Skin Antisepsis   2015-07-01 NICU  
Skin Care   2015-08-01 NICU  
Skin Injury Prevention Guidelines   2015-09-01 NICU  

Soother Use in the NICU

  2017-05-01 NICU  

Subgaleal Hemorrhage

  2011-06-01 NICU  
Sucrose Administration   2015-06-01 NICU  

Suctioning - Gastric and Esophageal Suctioning

  2015-10-01 NICU  
Surfactant Administration   2015-12-01 NICU  
T-Piece Ventilation   2015-12-01 NICU  

Transition to Cot

  2014-03-01 NICU  
Transport Incubator Use   2013-06-01 NICU  
Transpyloric Feeding Tube   2013-06-01 NICU  
Umbilical Line Insertion   2015-10-01 NICU  

Visiting Guidelines - Neonatal Nursery

  2015-12-01 NICU  
Vitamin and Mineral Supplementation   2015-05-01 NICU  
Vitamin K   2015-04-01 NICU  

CHAT Record for Obstetrical Patient

    Rural Obst  
Dinoprosone (Prostaglandin E2)   2015-08-01 Rural Obst Vaginal Insert for Ripening of the Cervix

Epidural for Labour - Management of Patient

  2015-08-01 Rural Obst  

Fetal Health Surveillance

  2015-08-01 Rural Obst  

Fetal Monitoring (Electronic, Internal)

  2015-08-01 Rural Obst  

Group B Strep Prophylaxis

  2015-08-01 Rural Obst  

Induction Augmentation of Labour (Oxytocin)

  2017-03-01 Rural Obst  

Magnesium Sulphate Infusion for the Prevention of Eclampsia

  2015-08-01 Rural Obst  

Management and Treatment of Postpartum Hemorrhage (PPH)

  2015-08-01 Rural Obst  

Management of Term Breech Presentation

  2015-08-01 Rural Obst  

Managing the Obstetrical Patient Requiring a C-section in the Main OR

  2015-08-01 Rural Obst  
Cervical Ripening, Induction, and C-section   2015-08-01 Rural Obst Booking Procedure

Non Stress Test

  2015-08-01 Rural Obst  
Obstetrical Emergency Initiation and Notification Process   2015-08-01 Rural Obst  

Outpatient Phone Tracking Record

  2015-08-01 Rural Obst  

Rapid Fetal Fibronectin Testing for Preterm Labour (fFN)

  2015-08-01 Rural Obst  

Rh Immune Globulin (WinRho)

  2015-08-01 Rural Obst  

Supplementation of the Breastfed Well Term Newborn

  2015-08-01 Rural Obst  

Vaginal Prostaglandin Administration (Prepidil, Prostin E2)

  2015-08-01 Rural Obst  

Bottle Feeding

  2015-08-01 Rural Nursery  


  2015-08-01 Rural Nursery  

Endotracheal Intubation - Assisting

  2015-08-01 Rural Nursery  

Falls Mitigation Strategies     

  2015-08-01 Rural Nursery  

Fetal Monitoring (Electronic - Internal) (IFM)

  2015-08-01 Rural Nursery  

Group B Streptococcal Disease - Neonatal Management

  2015-08-01 Rural Nursery  

Hearing Loss Screening

  2015-08-01 Rural Nursery  

Hepatitis B Prevention

  2015-08-01 Rural Nursery  

Human Milk Management

  2015-08-01 Rural Nursery  

Independent Double Check - High Alert Medications  

  2015-08-01 Rural Nursery  

Infant Car Seat Position Evaluation

  2015-08-01 Rural Nursery  

Infant Soothers

  2015-08-01 Rural Nursery  

Initial Newborn Bath

  2015-09-01 Rural Nursery  

Intramuscular (IM) Injection

  2015-08-01 Rural Nursery  

Intravenous Therapy

  2015-08-01 Rural Nursery  

Jejunostomy Tube Care and Feeds

  2015-08-01 Rural Nursery  

Line and Tubing Verification

  2015-08-01 Rural Nursery  

Maintaining Pediatric Peripheral Intravenous Lines Locking

  2015-08-01 Rural Nursery  

Monitoring and Transport of Pediatric Patients on Opioid Infusions and Low Dose Ketamine Infusions

  2015-08-01 Rural Nursery  

Oxygen Delivery

  2015-08-01 Rural Nursery  

Release from Responsibility form

  2015-08-01 Rural Nursery  

Responsibilities of Pediatric RNs and LPNs for Intravenous Infusions Site Care

  2015-08-01 Rural Nursery  

Skin Antisepsis

  2015-08-01 Rural Nursery  

Staff Responsibility to Pediatric Patient Risk of Entanglement

  2015-08-01 Rural Nursery  

Supplementation for the Breastfed Well Term Newborn

  2015-08-01 Rural Nursery  

Universal Pre-Discharge Transcutaneous Bilirubin Screening of Term and Late Preterm Infants

  2015-08-01 Rural Nursery  

Vitamin K Administration

  2015-08-01 Rural Nursery  

Well Newborn Feeding Assessment Protocol

  2015-08-01 Rural Nursery  

Enteral and Parenteral Nutrition


Adult Nutrition Support Manual - 2008
Guidelines in Adult Enteral Nutrition - May 2015
Med Pass Program Procedure
Closed Enteral Feeding System Information - August 2016
Temporary Substitutions for Adult Formulas - Feb. 2018
PeriOlimel® and Olimel® Standard Parenteral Nutrition Solutions
Clog-Zapper - Enteral Feeding Tube De-clogging System (Mar. 28, 2016)
Total Parenteral Therapy (TPN) Resources:
<"7575.asp" target="_blank">Drug Monographs: SMOFlipid Emulsion
Olimel / PeriOlimel Parenteral Nutrition
Travasol Amino Acid Solution

Alcohol Withdrawal       PMOS order from DataGroup #CV-0576 (10/2016) v.s
Assessment Form
Alcohol Withdrawal Information Pamphlet

<"ie/Page448.aspx" target="_blank">Cytotoxic - Learning / Resources Page, Mycobacterium Products


<"7575.asp" target="_blank">Drug Monographs, AHS Regional Parenteral Manual

Breastfeeding Policy - Baby Friendly Initiative (BFI)   2016-11-04 Corporate See CLiC for Learn Resource
Personal Linen   2015-06-18 Laundry  
Specialty Linen   2015-04-07 Laundry  
Washers and Dryers on Units   2015-04-07 Laundry  

<"1980.asp" target="_blank">Laboratory Services Resource Page (Lab Services)

      AHS Quick Reference Link Sites:
Collection Information
Lab Bulletins
Patient Instruction Sheets
Forms and Requisitions
Laboratory Departments/Disciplines
Information for Laboratory & Other Health Professionals
<"7503.asp">Glucometer - Resource Page       Roche Glucometer
<"assets/policy/clp-capital-md-sites-ptcare-body-nervous-external-lumbar-drain-8-8.pdf" target="_blank">Lumbar Drains resource page        
Management of Aggressive or Violent Behaviour   2012-07-03  Villa Caritas  
<"ie/Page475.aspx" target="_blank">Occupational Health and Safety Resource Page        
Peritoneal Dialysis Practice Documents - <"12719.asp">resource link        
Staff Education Fund II-110 2016-11-04 Corporate Tuition Fees
Purchasing Card (P-Card) IV-35 2016-11-04 Corporate  
Processing Reusable Surgical Textiles   2016-10-18 Laundry  
Corridors and Hallways with Autoscrubber   2016-10-21 EVS  
Medication Rooms   2016-10-21 EVS  
Bedside Furniture       2016-10-21 EVS  
Amnioinfusion   2013-01-01 Womens Health  
Anesthesia Requests   2015-07-01 Womens Health  
Bakri Balloon Catheter   2013-06-01 Womens Health  
Bladder Scanner BVI 9400   2011-03-01 Womens Health  
Breast Milk / Human Milk
Assessment of Milk Transfer
Storage of Expressed Breast Milk
Human Milk Misappropriation
Supplementation for the Breastfed Well Term Newborn
    Womens Health IPC Guidelines for Handling of Expressed Breast Milk
Breech Management at Term   2012-01-01 Womens Health  
Chorioamnionitis   2014-06-01 Womens Health  
Individual Privileges and Required Skills for General Practitioners   2012-01-01 Womens Health

Consultation Protocol – Obstetrics

Cord Care   2011-06-01 Womens Health  
Cord Sampling at Delivery   2011-06-01 Womens Health  
Diabetic Management of the Obstetrical Patient Guidelines   2016-07-01 Womens Health  
Early Pregnancy Loss Program (EPLP): November 2014
Surgical Management of a Non-viable Pregnancy
Medical Mgmt. of a Non-viable Intrauterine Pregnancy
Outpatient Expectant Mgmt. of Non-viable Intrauterine Pregnancy
    Womens Health  
Emergency Dept – Mgmt. of an Obstetrical Patients   2011-06-01 Womens Health  
Entonox - Use of   2011-06-11 Womens Health  
FentaNYL – Administration During Labour   2015-04-01 Womens Health  
Fetal Health Surveillance Womens Health Edmt Zone   2016-04-01 Womens Health  
Fetal Scalp Sample   2015-06-01 Womens Health  
Group B Strep (GBS):
Group B Strep – Maternal
Early Onset Neonatal Sepsis (EONS)
  2016-04-01 Womens Health  
Hepatitis B Prevention - Infants   2015-09-01 Womens Health  
HIV Perinatal Protocol - Regional Guidelines   2014-08-01 Womens Health  
Hypertensive Disorders of Pregnancy - March 1, 2018

Magnesium Sulfate Infusion for the Obstetrical Patient Guideline June 2011

Magnesium Sulfate Post Partum Admin. Dec. 2013
    Womens Health  
Induction & Augmentation of Labour   2014-06-01 Womens Health Standard Oxytocin Increment Table

Inpatient Transfer:

Grey Nuns (Mar. 2014)

Misericordia (January 2016)

    Womens Health  
Intrauterine Pressure Catheter (IUPC)   2011-08-01 Womens Health  
Magesium Sulfate for Fetal Neuroprotection in the Obs. Patient   2014-01-01 Womens Health  
Management of the Obstetrical Patient in Emergency   2011-08-01 Womens Health  
Managing Obstetrical Patients Requiring a Cesarean Section in the Main OR (Delivery in the Main OR)   2014-10-01 Womens Health  
Midwifery Guidelines for Physician Consultation and Transfer of Responsibility of Care   2016-04-01 Womens Health  
<"9307.asp">Newborn Metabolic Screen Policy Suite     Womens Health  
Non-Stress Test (NST)   2014-03-01 Womens Health  

Obstetrical Emergency

Stat 99 MCH (Dec. 2013)

Womens Health  
Obstetrical Operating Room Standards   2011-02-01 Womens Health  
Oxytocin Challenge Contraction Stress Test   2015-07-01 Womens Health  
Physician - Family Practice Privileges     Womens Health  
Placenta Processing for the Laboratory   2011-10-01 Womens Health  
Postpartum Bladder Management   2016-08-01 Womens Health  
Postpartum Hemorrhage Prevention and Treatment   2012-01-01 Womens Health  
Preterm Labour – Tocolysis   2007-01-01 Womens Health  
<"9537.asp">Safe Infant Sleep     Womens Health  
Skin to Skin Care   2015-11-01 Womens Health  
Sponge and Needle Count   2014-03-01 Womens Health  
Thermal Regulation Temperature Monitoring   2011-10-01 Womens Health  
Vaginal Birth after Cesarean Section (VBAC)   2014-06-01 Womens Health  

Visiting Policy
Grey Nuns

Off Duty Staff, Physicians and Volunteers

    Womens Health  
Vitamin K   2015-04-01 Womens Health  

Epidural Regional Analgesia / Anaesthesia Infusions

  2015-07-01 Womens Health  
Epidural for Labour - Mgmt. of Patients, Procedure   2015-07-01 Womens Health  
External Cephalic Version – ECV   2012-01-01 Womens Health  
Eyes, Prophylactic Care of the Newborn Eyes Prophylaxis / Timing   2012-10-01 Womens Health  
Falls Mitigation Strategies   2011-10-01 Womens Health  
Administration of Contrast Media in Lactating Patients II-A-56 2015-07-01 Diagnostic Img  
Booking Examinations-Specialty Imaging II-A-20 2015-07-01 Diagnostic Img  
Booking Examinations II-A-12 2015-07-01 Diagnostic Img  
Confidentiality II-A-40 2015-07-01 Diagnostic Img  
Consultation Request II-A-15 2015-07-01 Diagnostic Img  
Contrast Media Utilization/Administration II-A-55 2015-07-01 Diagnostic Img  
Emergency Service-Specialized Imaging II-A-10 2015-07-01 Diagnostic Img  
Fluoroscopic Equipment Utilization II-A-70 2015-07-01 Diagnostic Img  
Hours of Operation II-A-5 2015-07-01 Diagnostic Img  
Outpatient Referrals-External Health Care Facilities II-A-23 2015-07-01 Diagnostic Img  
Patient Care Following Diagnostic Nuclear Imaging Procedures II-A-90 2015-07-01 Diagnostic Img  
<"assets/policy/clp-di-prov-dis1-1-consent-exams-injection-iv-contrast.pdf">Patient Consent for Examinations Requiring the Injection of Intravenous Contrast Media     Diagnostic Img  
Patient Dress II-A-35 2015-07-01 Diagnostic Img  
Patient Transportation and Portering Service II-A-30 2015-07-01 Diagnostic Img  
Retention of Imaging Records II-A-45 2015-07-01 Diagnostic Img  
Scheduled Procedure Commencement II-A-25 2015-07-01 Diagnostic Img  
Sequencing of Abdominal Examinations Using Contrast Medium II-A-53 2015-07-01 Diagnostic Img  
Still Born Radiography II-A-85 2015-07-01 Diagnostic Img  
Diabetic Patients Treated with Metformin II-A-63 2015-07-01 Diagnostic Img Intravascular Contrast Media
Arthrogram – Knee IV-5 2015-07-01 Diagnostic Img  
Arthrogram – Shoulder IV-6 2015-07-01 Diagnostic Img  
Bronchoscopy IV-10 2015-07-01 Diagnostic Img  
Cardiac Fluoroscopy/Chest Fluoroscopy IV-15 2015-07-01 Diagnostic Img  
Cholangiogram T-Tube IV-20 2015-07-01 Diagnostic Img  
Colon (Barium Enema) IV-25 2015-07-01 Diagnostic Img  
Cystogram IV-30 2015-07-01 Diagnostic Img  
Endoscopic Retrograde Cholangiopancreatography IV-35 2015-07-01 Diagnostic Img ERCP
Esophagus IV-40 2015-07-01 Diagnostic Img  
Hysterosalpingogram IV-45 2015-07-01 Diagnostic Img  
Joint Aspiration IV-55 2015-07-01 Diagnostic Img  
Joint Injection IV-60 2015-07-01 Diagnostic Img  
Loopogram IV-65 2015-07-01 Diagnostic Img  
Lumbar Puncture IV-67 2015-07-01 Diagnostic Img  
Nephrostogram IV-75 2015-07-01 Diagnostic Img  
Retrograde Pyelogram IV-80 2015-07-01 Diagnostic Img  
Sialogram IV-85 2015-07-01 Diagnostic Img  
Sinogram IV-90 2015-07-01 Diagnostic Img  
Stomach and Duodenum IV-95 2015-07-01 Diagnostic Img  
Stomach and Duodenum and Follow-Through IV-105 2015-07-01 Diagnostic Img  
Swallowing Mechanism Assessments IV-110 2015-07-01 Diagnostic Img  
Urethrogram IV-120 2015-07-01 Diagnostic Img  
Abdominal Aortogram, Retrograde V-5 2015-07-01 Diagnostic Img Vascular
Arch (Thoracic) Aortogram V-10 2015-07-01 Diagnostic Img Vascular
Arterio-Venous Fistulogram V-15 2015-07-01 Diagnostic Img Vascular
Cerebral Angiography (Carotid and Vertebral Circulation) V-25 2015-07-01 Diagnostic Img Vacsular
IVC Filter Removal V-26 2015-07-01 Diagnostic Img Vascular
Percutaneous Transluminal Angioplasty V-30 2015-07-01 Diagnostic Img Vascular
Peripheral (Femoral or Antecubital) Arteriogram V-40 2015-07-01 Diagnostic Img Vascular
Perm Cath V-45 2015-07-01 Diagnostic Img Vascular
PICC Line Insertion V-50 2015-07-01 Diagnostic Img Vascular
Pulmonary Angiography V-60 2015-07-01 Diagnostic Img Vascular
Renal Arteriogram V-70 2015-07-01 Diagnostic Img Vascular
Trans-Brachial Angiogram V-80 2015-07-01 Diagnostic Img Vascular
Vascular Embolization V-90 2015-07-01 Diagnostic Img Vascular
Vascular Stent Insertion V-100 2015-07-01 Diagnostic Img Vascular
Vena Cavogram/Vena Cava Filter Insertion V-110 2015-07-01 Diagnostic Img Vascular
Abscess Drainage and Tube Insertion Percutaneous V-160 2015-07-01 Diagnostic Img Non-Vascular
Biopsies V-170 2015-07-01 Diagnostic Img Non-Vascular
Fallopian Tube Canalization V-180 2015-07-01 Diagnostic Img Non-Vascular
Gastrostomy Percutaneous V-190 2015-07-01 Diagnostic Img Non-Vascular
Percutaneous Nephrostomy V-195 2015-07-01 Diagnostic Img Non-Vascular
Pleurx Catheter Insertion V-197 2015-07-01 Diagnostic Img Non-Vascular
Sympathectomy Percutaneous V-200 2015-07-01 Diagnostic Img Non-Vascular
Lumbar, Thoracic or Celicac
Tube Exchange or Replacement Percutaneous V-205 2015-07-01 Diagnostic Img Non-Vascular
Ureteral Stent Insertion V-210 2015-07-01 Diagnostic Img Non-Vascular
Intravenous Injection of Iodinated Contrast and Screening form and patient questionnaire   2015-07-01 Diagnostic Img Computed Tomography
Computed Tomography Procedures Booking Authorization VI-1 2015-07-01 Diagnostic Img  
Computed Tomography, Cranium VI-5 2015-07-01 Diagnostic Img Head
Computed Tomography, Chest VI-10 2015-07-01 Diagnostic Img  
Computed Tomography, Abdomen and/or Pelvis VI-15 2015-07-01 Diagnostic Img  
Computed Tomography, Spines VI-25 2015-07-01 Diagnostic Img  
Percutaneous Biopsy Under CT Guidance VI-30 2015-07-01 Diagnostic Img Computed Tomography
Computed Tomography, Extremities VI-35 2015-07-01 Disgnostic Img Ultrasound
Abdomen VII-1 2015-07-01 Diagnostic Img Ultrasound
Amniocentesis VII-25 2015-07-01 Diagnostic Img Ultrasound
Arterial System VII-60 2015-07-01 Diagnostic Img Ultrasound
Biophysical Profile, Fetus VII-30 2015-07-01 Diagnostic Img Ultrasound
Biopsy Under Ultrasound Guidance VII-90 2015-07-01 Diagnostic Img Ultrasound
Breast VII-50 2015-07-01 Diagnostic Img Ultrasound
Carotid Doppler VII-70 2015-07-01 Diagnostic Img Ultrasound
Drainage Under Ultrasound Guidance VII-92 2015-07-01 Diagnostic Img Ultrasound
Echocardiography VII-80 2015-07-01 Diagnostic Img Ultrasound
Neonatal and Infant Heads VII-35 2015-07-01 Diagnostic Img Ultrasound
Obstetrical Ultrasound VII-20 2015-07-01 Diagnostic Img Ultrasound
Paracentesis Under Ultrasound Guidance VII-100 2015-07-01 Diagnostic Img Ultrasound
Pelvis VII-5 2015-07-01 Diagnostic Img Ultrasound
Percutaneous Renal Biopsy VII-95 2015-07-01 Diagnostic Img Ultrasound
Popliteal Space (Knee) VII-55 2015-07-01 Diagnostic Img Ultrasound
Pylorus VII-15 2015-07-01 Diagnostic Img Ultrasound
Scrotum (Testes) VII-10 2015-07-01 Diagnostic Img Ultrasound
Thoracentesis Under Ultrasound Guidance VII-105 2015-07-01 Diagnostic Img Ultrasound
Thyroid VII-40 2015-07-01 Diagnostic Img Ultrasound
Transesophageal Echocardiography VII-75 2015-07-01 Diagnostic Img Ultrasound
Venous Doppler Lower Limb +/- Popliteal Space VII-65 2015-07-01 Diagnostic Img Ultrasound
Venous Doppler Upper Limb VII-67 2015-07-01 Diagnostic Img Ultrasound
Cardiac First Pass Study VIII-50 2015-07-01 Diagnostic Img Nuclear Medicine - Cardiac
Cardiolite (MIBI) Rest/Stress Scan, Myocardial Perfusion Scan VIII-55 2015-07-01 Diagnostic Img Nuclear Medicine - Cardiac
Cardiolite (MIBI) Rest/Persantine Scan VIII-60 2015-07-01 Diagnostic Img Nuclear Medicine - Cardiac
Rest Gated Cardiac Blood Pool Scan VIII-65 2015-07-01 Diagnostic Img Nuclear Medicine - Cardiac
Thallium Viability Scan VIII-75 2015-07-01 Diagnostic Img Nuclear Medicine - Cardiac
Thallium Stress/Rest/Reinjection Scan VIII-80 2015-07-01 Diagnostic Img Nuclear Medicine - Cardiac
Brain Scan Flow and Scan (CNS, non routine) VIII-5 2015-07-01 Diagnostic Img Nuclear Medicine - Central Nervous System
Brain Flow and Scan (Perfusion, routine) VIII-10 2015-07-01 Diagnostic Img Nuclear Medicine - Central Nervous System
Shunt Patency Scan VIII-20 2015-07-01 Diagnostic Img Nuclear Medicine - Central Nervous System
Arm Venogram With Lung Scan VIII-100 2015-07-01 Diagnostic Img Nuclear Medicine - Circulatory
Lymphoscintigram VIII-110 2015-07-01 Diagnostic Img Nuclear Medicine - Circulatory
Red Cell Venogram VIII-115 2015-07-01 Diagnostic Img Nuclear Medicine - Circulatory
Sentinel Lymph Node Lymphoscintigram VIII-120 2015-07-01 Diagnostic Img Nuclear Medicine - Circulatory
Superior Vena Cavogram VIII-125 2015-07-01 Diagnostic Img Nuclear Medicine - Circulatory
Venogram With Lung Scan – Bilateral Legs VIII-130 2015-07-01 Diagnostic Img Nuclear Medicine - Circulatory
Gastric Emptying Scan VIII-150 2015-07-01 Diagnostic Img Nuclear Medicine - Gastrointestinal
Gastroesophageal Reflux VIII-155 2015-07-01 Diagnostic Img Nuclear Medicine - Gastrointestinal
GI Bleed Scan (Red Blood Cell) VIII-160 2015-07-01 Diagnostic Img Nuclear Medicine - Gastrointestinal
GI Bleed Scan (Sulphur Colloid) VIII-165 2015-07-01 Diagnostic Img Nuclear Medicine - Gastrointestinal
Meckel’s Diverticulum VIII-170 2015-07-01 Diagnostic Img Nuclear Medicine - Gastrointestinal
Peritoneal Scan VIII-175 2015-07-01 Diagnostic Img Nuclear Medicine - Gastrointestinal
Capoten Renogram VIII-250 2015-07-01 Diagnostic Img Nuclear Medicine - Genitourinary
Diuretic Renogram VIII-255 2015-07-01 Diagnostic Img Nuclear Medicine - Genitourinary
DTPA Renogram VIII-260 2015-07-01 Diagnostic Img Nuclear Medicine - Genitourinary
Effective Renal Plasma Flow (ERPF) VIII-265 2015-07-01 Diagnostic Img Nuclear Medicine - Genitourinary
Glomerular Filtration Rate VIII-270 2015-07-01 Diagnostic Img Nuclear Medicine - Genitourinary
MAG-3 Renogram VIII-275 2015-07-01 Diagnostic Img Nuclear Medicine - Genitourinary
Nuclear Cystogram VIII-280 2015-07-01 Diagnostic Img Nuclear Medicine - Genitourinary
DSMA/Renal Scan VIII-285 2015-07-01 Diagnostic Img Nuclear Medicine - Genitourinary
Testicular Scan VIII-290 2015-07-01 Diagnostic Img Nuclear Medicine - Genitourinary
Adrenal Scan With Meta-Iodobenzylguanadine VIII-350 2015-07-01 Diagnostic Img

Nuclear Medicine - Glandular

Nuclear Dacrocystogram VIII-355 2015-07-01 Diagnostic Img Nuclear Medicine - Glandular
Octeriotide Scan VIII-357 2015-07-01 Diagnostic Img Nuclear Medicine - Glandular
Parathyroid Scan VIII-360 2015-07-01 Diagnostic Img Nuclear Medicine - Glandular
Thyroid Scan VIII-370 2015-07-01 Diagnostic Img Nuclear Medicine - Glandular
Thyroid Therapy (For Treatment of Hyperthyroidism) VIII-375 2015-07-01 Diagnostic Img Nuclear Medicine - Glandular
Thyroid Uptake VIII-380 2015-07-01 Diagnostic Img Nuclear Medicine - Glandular
Gallbladder Ejection Fraction VIII-200 2015-07-01 Diagnostic Img Nuclear Medicine - Hepatic
HIDA Scan (Hepatobiliary) VIII-205 2015-07-01 Diagnostic Img Nuclear Medicine - Hepatic
Liver and Spleen Scan VIII-210 2015-07-01 Diagnostic Img Nuclear Medicine - Hepatic
Red Blood Cell Liver Scan VIII-215 2015-07-01 Diagnostic Img RBC Liver Scan
Nuclear Medicine - Hepatic
Perfusion Lung Scan VIII-400 2015-07-01 Diagnostic Img Nuclear Medicine - Pulmonary
Ventilation Lung Scan – Aerosol VIII-405 2015-07-01 Diagnostic Img Nuclear Medicine - Pulmonary
Bone Flow Study VIII-300 2015-07-01 Diagnostic Img Nuclear Medicine - Skeletal
Bone Marrow Scan VIII-305 2015-07-01 Diagnostic Img Nuclear Medicine - Skeletal
Bone Scan VIII-310 2015-07-01 Diagnostic Img Nuclear Medicine - Skeletal
Gallium Scan VIII-455 2015-07-01 Diagnostic Img Nuclear Medicine
Scinti-Mammography VIII-460 2015-07-01 Diagnostic Img Nuclear Medicine
White Blood Cell (WBC) Scan VIII-470 2015-07-01 Diagnostic Img Nuclear Medicine
Renal Extracorporeal Shock Wave Lithotripsy IX-1 2015-07-01 Diagnostic Img Lithotripsy
Biliary Extracorporeal Shock Wave Lithotripsy IX-5 2015-07-01 Diagnostic Img Lithotripsy
MRI Abdomen/Pelvis X-15 2015-07-01 Diagnostic Img  
MRI Angiography X-20 2015-07-01 Diagnostic Img  
MRI Brain X-25 2015-07-01 Diagnostic Img  
MRI Musculoskeletal (MSK) X-35 2015-07-01 Diagnostic Img  
MRI Pediatrics X-40 2015-07-01 Diagnostic Img  
MRI Spine X-45 2015-07-01 Diagnostic Img  
MRI Screening for Orbital metallic foreign bodies X-50 2015-07-01 Diagnostic Img  

Off-duty Staff, Physicians and Volunteers as Visitors

I-D-30 2005-05-13 Edm Acute  
Donations I-F-5 2011-08-23 Edm Acute  
Fundraising I-F-10 2011-08-23 Edm Acute  

Medical Emergency Response Procedure

II-90 2012-02-27 Edm Acute  

Safe Use of Lasers

II-175 2017-11-10 Corporate  

Use of Lobby Space for Fundraising and/or Display Activities

I-F-20 2015-04-10 Edm Acute  

Capital Equipment Purchases / Requisitions

IV-B-10 2010-03-05 Edm Acute  

Decorative Lighting, Materials, and Displays

IV-A-20 2016-11-07 Edm Acute  

Illegal Drugs or Weapons; Patients

V-C-1 2008-01-16 Edm Acute  

Lost and Found Property

V-C-15 2006-10-12 Edm Acute  

Petty Cash Purchases

V-A-41 2010-01-15 Edm Acute  
Instructions for use of the Nursing Assessment and Care Record (Grey Nuns & Misericordia)     Edm Acute Form CH-0774
Activation of the Rapid Response Team II-7 2017-03-10 Edm Acute  
Patient Portering II-44  2015-04-10 Edm Acute  
Automatic Stop Orders III-10 2008-10-10 Edm Acute  
Direct IV Medication Administration VII-B-310 2018-02-09 Corporate <"Page1211.aspx" target="_self">Learning Module
Medications for Patients on Pass to Family and Community Environment III-110 2007-09-28 Edm Acute  
Patient Controlled Analgesia (PCA) via PCA Pump – Care of the Patient and Infusion III-130 2010-05-11 Edm Acute <"Page1211.aspx" target="_self">Learning Module
Clinical Documentation III-120 2018-02-09 Corporate Patient Chart, Charting
Resource:  Signature Log form #90219 (please order form through DataGroup) 
Safekeeping Patient Valuables V-45 2006-06-06 Edm Acute  
Assessment and Care of the Adult Following Surgery or Procedures Completed Under General, Intraspinal Anaesthetic and/or Regional Nerve Block VII-A-5 2009-02-27 Edm Acute Accompanying forms for VII-A-5
CH-1343 (Jul 2008) Adult Inpatient Pain Assessment & Analgesic Monitoring Flow Sheet
CH-1344 (Jul 2008) Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet Guidelines (Sheet #1)
CH-1345 (Jul 2008) Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet Guidelines (Sheet #2)
CH-1346 (Jul 2008) Adult Inpatient Pain Assessment and Analgesic Monitoring Flow Sheet Guidelines (Sheet #3)     
Regional Nerve Block VII-A-10 2010-07-05 Edm Acute Learning Package - January 15, 2018
Epidural Catheters VII-A-15 2010-09-29 Edm Acute Learning Module Jan. 15, 2018
Enteral Tube; Insertion, Nutrition and Medication Administration, Decompression/Evacuation VII-D-10 2010-09-03 Edm Acute  
Feeding / Swallowing Problems VII-D-15 2005-06-02 Edm Acute  
Oral Care Protocol for Adult Patients VII-D-23 2009-07-13 Edm Acute  
Suprapubic Catheter Removal VII-E-15 2012-06-26 Edm Acute  
Specialized Footcare VII-F-5 2009-07-14 Edm Acute  
Removal of Wound Closure and Drainage Devices VII-F-10 2009-05-06 Edm Acute  
Therapeutic and General Mobilization VII-F-15 2009-07-13 Edm Acute  
Pressure Ulcer Assessment and Prevention VII-F-20 2010-06-21 Edm Acute Standards of Practice
Pressure Ulcer Assessment and Prevention – Heels VII-F-25 2010-06-21 Edm Acute  
Cardiac Catheterization VIII-10 2015-09-11 Edm Acute  
Specimen Identification, Labelling and Transport VIII-20 2016-11-04 Edm Acute  
Misoprostol - Inducation of Labour   2016-05-01 Rural Obst  
Allied Health Care Providers I-5 2010-04-01 Continuing Care  
Automatic Stop Orders III-5 2010-04-01 Continuing Care  
Residents on Temporary Transfer to Other Care Providers III-77 2010-04-01 Continuing Care  
Medications for Residents on Pass to Family and Community Environment III-78 2010-02-01 Continuing Care  
Use of Smartpumps in Continuing Care III-105 2010-07-01 Continuing Care  
Restraint Procedure (Interim) - Continuing Care               Continuing Care Resources:
Clinical Practice Guidelines for Residents with Diabetes II-C-1 2010-07-01 Continuing Care Resources:
Long Term Urinary Catheter Maintenance II-C-30 2010-04-01 Continuing Care Clinical Pathway
Wound Management II-C-50 2010-07-01 Continuing Care  
Warfarin Administration III-110 2010-08-01 Continuing Care  
Management of Aggressive or Violent Behaviour in Continuing Care IV-27 2010-06-01 Continuing Care  
Observation Levels  VII-B-215 2016-12-09 Corporate Learning modules available on CLiC - under Addictions and Mental Health
Privileges and Passes VII-B-217 2016-12-09 Corporate Learning modules available on CLiC - under Addictions and Mental Health
Environmental Risk Assessment VII-B-220 2016-12-09 Corporate Learning modules available on CLiC - under Addictions and Mental Health
Search of Patient Property VII-B-225 2016-12-09 Corporate Learning modules available on CLiC - under Addictions and Mental Health
Transfer or Discharge of Patients VII-B-230 2016-12-09 Corporate Learning modules available on CLiC - under Addictions and Mental Health
Trauma in Pregnancy   2016-07-01 Womens Health  
Deliveries in the Absence of Medical Staff   2015-07-01 Womens Health  
Suicide Risk Screening, Assessment and Management VII-B-200 2016-12-09 Corporate Learning modules available on CLiC - under Addictions and Mental Health
CV-0603, Suicide Risk Screen / Assessment
CV-0604, Suicide Risk & Screen Assessment
CV-0600, My Safety Plan
Inpatient Death by Suicide VII-B-210 2016-12-09 Corporate Learning modules available on CLiC - under Addictions and Mental Health
Inpatient Attempted Suicide VII-B-205 2016-12-09 Corporate Learning modules available on CLiC - under Addictions and Mental Health
Waiting Rooms   2016-12-08 ES  
Bassinets, Baby Warmers, Isolettes   2016-12-08 ES  
Initial Newborn Bathing   2018-01-01 Womens Health  
Hyperbilirubinemia Screening and Phototherapy    2016-04-01 Womens Health  
Blood Sampling Arterial Lines   2016-11-01 NICU  
No Smoking Policy I-40 2017-01-13 Corporate  
Medication and Parenteral Fluid Admin by Alaris SMART Infusion Pumps III-103 2009-03-06 Edm Acute Infusion Pump Education Module on CLiC
<"12436.asp">Provincial Infusion Pump Education Page
Provincial Resource:  <"14275.asp">Users Manual & Drug Libraries
When to use an Infusion Pump
Perioperative Service Delivery Policy VII-B-250 2017-03-10 Corporate  
Critical Congenital Heart Defect Screening for Well New Borns     2016-08-01 Womens Health CCHD     
Emergency / Disaster Managemnt Response I-25 2017-02-10 Corporate  
Stroke Algorithms - Grey Nuns Hospital       Inpatient - Algorithm for Suspected Ischemic Stroke  
ER - Algorithm for Suspected Ischemic Stroke  
ICU / Critical Care - Algorithm for Suspected Ischemic Stroke 
Swallow Screening Algorithm
Initial Infant Bathing   2017-03-01 Rural Obst  
Folding Linens, Stocking Carts, and Linen Transport   2017-03-10 Laundry  
Laundry Services Safety       2017-03-10 Laundry  
Laundry / Linen Cart Cleaning   2017-03-10 Laundry  
Suggested Anaesthesia Consultation Procedure   2015-07-01 Womens Health  
Self Administration of Medication (SAM)     VII-A-65 2017-09-01 Corporate Appendices to SAM Policy & Procedure: Prescriber Information
SAM Fact Sheet    
Infant Discharge Procedure   2015-09-01 Womens Health  
Wound Care       <"11187.asp">Resource Page
Burn Management     Camrose Resource Documents:  
Burn Management Guidelines
<"assets/policy/clp-central-zone-emergency-burn-management-guideline.pdf">Practice Support Document
Ordering Meal Trays in the Emergency Department   2017-04-06 NFS  
Maintenance Program VII-C-40 2017-05-05 Corporate Continuing Care
Resident Immunizations:  Influenza and Pneumococcal VII-C-50 2017-10-20 Corporate Continuing Care
Resource Documents:
Independent Double Check (IDC)    VII-A-70 2017-07-10 Corporate Prescriber Information
Fact Sheet for Staff
Education PowerPoint
Checklist for IDC 
Infusion Line and Tubing Verification      VII-A-75 2017-07-10 Corporate Prescriber Information
Fact Sheet for Staff
Education PowerPoint
Checklist for Infusion Line and Tubing Verification
Triage Guidelines    2017-04-01  Camrose   
Patient Controlled Analgesia via PCA Pump     2017-02-22  Camrose   
Epidural Blood Patch    2017-05-14  Camrose   
Criteria to Support Obstetric Care at St. Mary's Hospital, Camrose    2017-06-01  Rural Obst   
Lost and Found    2017-04-12  Camrose   
Breast Milk Substitute Feeding    2017-05-25  Womens Health   
Cup Feeding    2017-05-01  Womens Health   
Term Infant Decanting Procedure   2017-03-01  Womens Health   
Decanting Procedure for Infant Breast Milk Substitute         2017-05-01  NICU   
Nipple Shields  Use     2017-05-01  NICU   
Handling of Soiled Linen    2016-10-18  Laundry   
On-site Laundry Contingency Plan    2017-04-27  Laundry   
Linen Repair and Discard    2017-02-09  Laundry   
Linen Inventory Quota Management    2017-05-16  Laundry   
Washing and Drying of Linen    2017-04-18  Laundry   
Laundry Services Quality Assurance    2017-05-16  Laundry   
Waiting Rooms and Patient Lounges    2016-12-08  EVS   
Handling of Soiled Linen - Laundry Services    2016-10-18  EVS   
OR Theatre Between Case Cleaning (Change Over)    2017-03-17  EVS   
Blood and Body Fluids - Carpet and Upholstery    2017-06-29  EVS   
OR Theatre Cleaning - End of Day / Isolation     2016-12-19  EVS   
Assistive Equipment (including Technology Aides and Medical/Surgical Supplies)  VII-C-35  2017-08-18  Corporate  Continuing Care 
Move In  VII-C-60  2017-08-18  Corporate  Continuing Care
Resource Documents:
Move Out  VII-C-65  2018-04-06  Corporate  Continuing Care
Resource Document - Move-Out Checklist  
Nail Care  VII-C-45  2017-08-18  Corporate  Continuing Care 
Pain Management  VII-C-70  2017-08-18  Corporate  Continuing Care
Resource Document - Pain Assessment Tool 
Staff Training   VII-C-75  2017-08-18  Corporate  Continuing Care
Resource Document - Staff Education Passport  
Continuing Care Desktop link
Transfer of Resident to Acute Care  VII-C-85  2017-08-18  Corporate  Continuing Care
Resource Document - Move-Out / Transfer Checklist 
Managed Risk Agreement  VII-C-55  2017-09-15  Corporate  Continuing Care, Negotiated Risk
Resource Documents:
Use of Electronic Monitoring, Recording Devices and Cameras by Patients, Residents and Alternate Decision Makers  X-70  2017-09-15  Corporate  Visitors taking pictures of staff 
Resource Documents:
Foodbourne Illnes (Suspected / Confirmed)    2017-09-22  NFS   
Use of Medical Marijuana by Patients and Residents While in Care         
Intraosseous:  Assisting with Insertion and Removal   2017-06-01  NICU   
Therapeutic and General Mobilization of Residents  VII-C-95  2017-11-10  Corporate  Continuing Care 
Procedural Sedation        VII-B-430  2018-01-01  Corporate  Resources:
Room Service:  Business Continuity in the Event of a Computer Failure    2017-11-06  NFS   
Room Service:  Advance Meal Orders             2017-11-24  NFS   
Room Service:  Ambassador Record Keeping        2017-11-24  NFS   
Room Service:  Parameters for Food Ordering    2017-10-26  NFS   
Room Service:  Guest Trays    2017-11-24  NFS   
Transportation  VII-C-90  2018-01-12  Corporate  Continuing Care 
Discharged Patient Health Records (in Paper Format)  III-115  2018-02-09  Corporate   
Suspected Sepsis Assessment and Treatment in the Adult Patient  PSD #3  2018-02-09    Emergency Department 
Ibuprofen for the Treatment of Pain or Pain/Discomfort Due to a Fever for the Pediatric Patient  PSD #2  2018-02-09    Emergency Department 
Pest Control:  Small Rodent Removal, Clean Up and Disposal  2017-04-17  EVS   
Pest Control  2017-08-21  EVS   
Non Powered Wheelchairs - Manual Washer  2016-08-18  EVS   
Non Powered Wheelchairs - Multipurpose Washer  2016-08-17  EVS   
Acetaminophen for Treatment of Pain or Pain/Discomfort Due to a Fever  PSD #1  2018-02-09    Emergency Department 
Oral Sucrose Administration - Pre-Procedural Analgesia  PSD #4  2018-02-09    Emergency Department 
Assessment and Reassessment of Patients  PSD #5  2018-02-09    Emergency Department 
Glycemic Management Policy
Hyperglycemic Management & Treatment Procedure (VII-B-465)
Hypoglycemic Management & Treatment Procedure (VII-B-470)
VII-B-460  2018-03-09  Corporate  Diabetes, Insulin
Dysphagia (Swallowing Disorder) and Eating Concerns  VII-C-80  2018-04-06  Corporate  Continuing Care 
Palliative and End of Life Care  VII-C-115  2018-04-06  Corporate  Continuing Care 
Oral Health  VII-C-110  2018-05-11  Corporate  Continuing Care:  Oral Care, Teeth Brushing
Enteral Nutrition  VII-C-100  2018-04-06  Corporate  Continuing Care 
Nutrition and Hydration     VII-C-105  2018-04-06  Corporate  Continuing Care 
Meal Trays and Small Wares - Contaminated with Biomedical Waste  3.2.3  2018-03-15  NFS   
Mobile Wireless Devices and Services  IV-25  2018-05-11  Corporate  Cell Phones