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Corporate Policies & Procedures

February 08 , 2018

From the office of Jon Popowich, Chief Quality & Privacy Officer 

New Corporate Policies and Procedures

      • Clinical Documentation
      • Discharged Patient Health Records (in paper format)*
      • Direct IV Medication Administratio

Revised Corporate Policies/Procedures 

      • Pre-Printed Medication Order Sets (PMOS)

PLEASE NOTE: You can view the policies/Procedures (with the changes highlighted) under New/Updated Corporate Policies in the "Corporate Services" section of the Covenant Health Medical Staff Portal.

 

III-120, Clinical Documentation  

    • This policy outlines fundamental clinical documentation requirements that must be followed by health care providers in all care settings.
    • Health care providers shall maintain accurate and complete clinical records of interactions with patients and families. Documentaion shall reflect an accurate, clear and comprehensive record of the patient's perspective regarding their health care needs, goals and preferences, the health care provider's communication, assessments, interventions and the patient outcomes.
    • Learning resources have been updated to alight with policy requirements and will be available to health care provider staff.

NOTE: This new corporate poilicy and procedure supersedes and replaces any previous site policies on this topic, including but not limited to Edmonton Acute Care Policy #V-20, Patient Chart Documentation and  Continuing Care Policy #V-5, Clinical Records Documentation Guideline.

INFO: If you have any questions specific to this policy and procedure, please contact Cyndee Johnson, Quality Consultant, by phone at 780.735.2091 or email her.

 

II-115, Discharged Patient Health Records (in paper format)

    • This policy helps minimize risk of health record loss by providing standardized processes for the management of discharged patient health records.
    • When a patient is discharged from an acute care facility, the health record is to be received with the Health Records Department 24 hours post discharge. Please contact the Health Records Department if an exception is required.
    • In the case of inpatient or ED records that have not been returned to Health Records, Health Records staff will follow the COV HIM Missing Record Guideline and appropriate reporting to Information and Privacy.

NOTE: This new corporate policy and procedure supersedes and replaces any previous site policies on this topic.

INFO: If you have any questions specific to this policy and procedure, please contact Cheryl Trylinski, Manager, Health Information Management at 780.735.2380 or email her.

 

VII-B-310, Direct IV Medication Administration

    • This policy provides health care professionals clear, consistent, and evidence-informed direction for direct IV medication administration in all Covenant Health settings.
    • Health care professionals are responsible to self-identify learning needs and undertake appropriate measures to ensure ongoing and continual competency.

NOTE: This new corporate procedure supersedes and replaces any previous unit/site versions including, but not limited to, Edmonton Acute, Patient Care Policy # III-45, Direct IV Medication Administration.

INFO: If you have any questions specific to this policy and procedure, please contact the Clinical Nurse Specialist for Parenteral Therapy by phone at 780.735.2593.

 

VII-B-445, Pre-Printed Medication Order Sets (PMOS)

    • Units/programs, medical leaders, staff and physicians shall ensure that they are using the most current version of Covenant Health-approved PMOS.
    • Development of a PMOS should involve the following stakeholders (as appropriate):
      1. physicians (program or site);
      2. nurse practitioners;
      3. pharmacists;
      4. nurses;
      5. allied health care professionals;
      6. unit/program manager and/or delegate;
      7. appropriate clinical content experts;
      8. any other stakeholders impacted by the PMOS.

NOTE: This new corporate policy and procedure supersedes and replaces any previous site policies on this topic.

INFO: If you have any questions specific to this policy and procedure, please contact Gillian Mah-Thompson, Medication Management, by phone at 780.342.9003 or email her.

 

 

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