Montana State Hospital
Policy Manual -- Volume II
Table of Contents
August 1, 2006
Policy # |
Description |
Last Issue |
|
|---|---|---|---|
Section XII -- Infection Control |
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| Body Piercing and Tattooing Prohibited | #IC-17 | To prevent risk of infection or other physical or emotional harm to patients from body piercing or tattooing during hospitalization. | 05/02/2008 |
| Employee Health Record & Immunization/Testing Requirements | #IC-02 | To provide current record of all employees' immunization and tuberculosis screening status and explain immunization and testing requirements of emlployees | 04/24/2007 |
| Exposure Control Plan | #IC-03 | Establishes responsibilities to minimize risk of acquiring bloodborne disease due to occupational exposure | 12/18/2002 |
| Guidelines for Isolation Precautions | #IC-11 | Isolation techniques to prevent the spread of disease | 12/18/2002 |
| Handling
Needles and Sharps |
#IC-04 | Procedures for disposal of needles and sharps | 12/18/2002 |
| Handwashing | #IC-05 | Handwashing procedures | 12/18/2002 |
| Hepatitis B Vaccination Program | #IC-06 | Provision of Hepatitis B vaccines to employees | 08/31/2007 |
| Infection Control - Care of Contaminated Articles of Clothing and Linen | #IC-07 | Procedures for handling contaminated articles of clothing and linen | 12/18/2002 |
| Infection Control Plan | #IC-09 | Describes MSH Infection Control Program | 12/18/2002 |
| Infection Report | #IC-10 | Establishes system for keeping records on patient infections | 12/18/2002 |
| Management of an Employee with an Occupational Exposure to a Bloodborne Pathogen | #IC-12 | Procedures to be taken in the event of an accidental exposure to bloodborne pathogens | 12/18/2002 |
| Nosocomial Infections | #IC-13 | Classification, care, and review procedures of nosocomial infections | 03/31/2003 |
| Personal Protective Equipment | #IC-14 | Procedures to assure the availability of personal protective equipment and training in proper use | 12/18/2002 |
| Standard Precautions | #IC-15 | Describes procedures for prevention of exposure to bloodborne pathogens | 12/18/2002 |
| Tuberculosis Surveillance for Patients of Montana State Hospital | #IC-16 | Guidelines for TB screening of MSH patients | 04/24/2007 |
Section XIII -- Medical Staff |
|||
| Credentialing and Privileging | #MS-01 | Defines procedures for credentialing and privileging of physicians and dentists | 08/22/2006 |
| Physician On-Call Coverage | #MS-02 | Provision of on-call physician/psychiatrist coverage | 10/03/2007 |
Section XIV -- Nursing Services |
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| Medication Administration and Safe Handling, Principles of | #NS-02 | Administration and handling of medications | 05/09/2008 |
| Nursing Assessment and Diagnosis | #NS-03 | Nursing Assessment procedures | 01/25/2008 |
| Pharmacy Night Locker | #NS-05 | Addresses access to medications at night | 05/20/2002 |
Section XV -- Patient Rights |
|||
| Informed Consent for Treatment | #PR-02 | Procedures for obtaining a patient's informed consent
for treatment |
08/22/2006 |
| Patient Grievance Procedure | #PR-03 | Describes the Patient Grievance Process | 01/14/2008 |
| Patient Rights and Grievance Procedure Information | #PR-04 | Procedure for presenting information to patients on their Rights and Grievance Procedure | 08/15/2007 |
| Voting Rights of Patients | #PR-05 | Procedures for providing assistance to patients wishing to exercise their right to vote | 04/26/2007 |
Section XVI -- Physical Health |
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| Adverse Drug Reaction Reporting | #PH-10 | Procedures for reporting adverse drug reactions |
08/22/2006 |
| Death and Autopsy | #PH-01 | Procedures to be followed upon the death of a patient | 08/22/2006 |
| Dietary
Supplement |
#PH-02 | Prohibits use of herbal supplements | 09/11/2006 |
| Informing/Communicating
Changes in Patient's Condition |
#PH-03 | Responsibility for providing information about changes in physical health to family members | 08/22/2006 |
| Medical
Clinic Services |
#PH-04 | Operation of the Medical Clinic | 08/22/2006 |
| Medical Emergency Response -- Initiating a "Code Blue" | #PH-11 | To provide a plan for response to medical emergencies | 05/02/2005 |
| Medical Marijuana | #PH-13 | To describe procedures for handling medical marijuana legally in the poossession of persons-served at the time of admission. | 08/01/2007 |
| Metabolic Syndrome Policy | #PH-12 | To educate patients on the risk factors that lead to Metabolic Syndrome and to screen selected patients for Metabolic Syndrome. | 04/06/2007 |
| Organ
and Tissue Donation |
#PH-05 | MSH will not routinely attempt to identify potential organ and tissue donors | 05/02/2008 |
| Physical
Health Assessment |
#PH-06 | Provision of physical exams | 08/22/2006 |
| Procedure
for Obtaining Informed Consent for Medical and Surgical Procedures |
#PH-07 | Addresses informed consent for surgical procedures | 08/22/2006 |
| Respiratory
Therapy Services |
#PH-08 | Provision of Respiratory Therapy Services | 09/11/2006 |
| Surgical Procedures, Use of Anesthesia and Blood Products at Montana State Hospital | #PH-09 | Describes limited surgical procedures provided at MSH | 08/22/2006 |
Section XVII -- Psychology Services |
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| Psychological Assessment and Evaluation | #PGS-01 | Describes psychological assessment and evaluation services at MSH | 10/24/2003 |
Section XVIII -- Psychiatric Services |
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| Clozaril
and Seroquel Standard Titration Schedules |
#PS-01 | Protocol for prescribing Clozaril | 08/22/2006 |
| Involuntary
Medications |
#PS-02 | Procedures for involuntary medication administration as allowed under Montana Statute | 08/22/2006 |
| Practitioner
Review of Patient Medication Regimen |
#PS-03 | Procedures for meeting requirements of 53-21-145 which require weekly review of medication | 08/22/2006 |
| Psychiatric
Assessments |
#PS-04 | Psychiatric assessment procedures | 08/22/2006 |
| Standing
Order: Drug Guidelines for Lab |
#PS-05 | Standardized lab tests for patients taking anticonvulsant and antipsychotic drugs | 08/22/2006 |
Section XIX -- Quality Improvement |
|||
| Death Review | #QI-01 | Procedures for reviewing patient deaths to evaluate quality of care | 08/22/2006 |
| Quality
Improvement Plan |
#QI-02 | Development of annual Quality Improvement Plan | 02/28/2007 |
| Seclusion and Restraint Committee | #QI-04 | To provide a post-incident review process for all restraint and seclusion interventions. |
08/17/2007 |
| Sentinel/Significant
Event Review |
#QI-05 | Guidelines for conducting a risk-prevention analysis in response to significant or sentinel events | 04/06/2007 |
Section XX -- Rehabilitation Therapy Services |
|||
| Centralized
Referred Rehabilitation Services |
#RTS-01 | Process for referring patients for centralized rehabilitation therapy services | 10/24/2003 |
| Chemical
Dependency Assessment and Referral |
#RTS-02 | Chemical Dependency Assessment | 09/01/2006 |
| Rehabilitation
Assessment |
#RTS-03 | Completion of Rehabilitation Therapy Assessments and Care Plans | 10/24/2003 |
| Resident
Employment / Vocational Therapy Program |
#RTS-04 | Guidelines for the employment and vocational training of patients as part of a comprehensive treatment and rehabilitation program and to provide a therapeutic work experience. | 06/30/2003 |
Section XXI -- Safety |
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| Contraband
and Searches |
#SF-02 | Defines contraband and establishes search procedures | 05/02/2008 |
| Environment
of Care Coordinating Group |
#SF-03 | Responsibilities of the Environment of Care Coordinating Group | 07/13/2007 |
| Hazardous Condition
Reporting Policy |
#SF-06 | Outlines procedures for reporting and responding to possible hazardous conditions affecting the overall safety of patients, employees and visitors of MSH. | 03/28/2007 |
| Incident
Response and Reporting |
#SF-04 | Describes response procedures for different types of incidents and completion of the Incident Report Form | 05/21/2007 |
| Medical Device Reporting | #SF-05 | Procedures for meeting FDA requirements for reporting problems with medical devices | 06/06/2003 |
| Workman's Compensation | #SF-07 | Identifies responsibilities in the event of a work-related injury that results in Worker's Compensation benefits. | 03/28/2007 |
Section XXII -- Social Services |
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| Social Assessment, (Initial, Interim, Annual, and Forensic) | #SS-01 | Completion of Social Work Assessments | 11/07/2003 |
Section XXIII -- Staff Development |
|||
| Tour Requests & Procedures | #SD-01 | Procedures for conducting tours of MSH for educational groups, the media, etc. | 07/13/2007 |
Section XXIV -- Support Services |
|||
| Preventative Maintenance Program | #SPS-01 | Describes preventative maintenance program | 06/06/2003 |
Section XXV -- Treatment |
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| Abnormal Involuntary Movement Scale (AIMS) Examination for Tardive Dyskinesia | #TX-01 | AIMS assessment procedures | 08/22/2006 |
| Advance Directives (Declarations) | #TX-02 | Advance Directives | 08/22/2006 |
| Allegations of Abuse or Neglect | #TX-17 | Procedures to be taken when allegations of patient abuse occur | 11/17/2004 |
| Animal Visitation | #TX-21 | Guidelines allowing patients to have personal visits from people bringing pets and for the use of animals as part of treatment and rehabilitation programs provided by MSH. | 03/30/2007 |
| Campus Privileges | #TX-04 | Types of unsupervised campus privileges allowed patients and campus pass boundary map | 07/13/2007 |
| Consultation Services | #TX-05 | Procedures for obtaining consultations from other professionals at MSH or in the community | 08/22/2006 |
| Crisis Intervention Team | #TX-18 | Provides guidelines for utilizing a team approach to crisis intervention | 05/09/2008 |
| Escorting Patients Off Grounds | #TX-27 | To provide for safety and security when escorting patients off grounds | 03/14/2007 |
| Event Review | #TX-25 | To provide for a process to review every event leading to the use of seclusion or restraints and to review other significant events that result in serious physical aggression toward other patients and staff | 05/02/2005 |
| Guardianship | #TX-07 | Procedures for guardianship | 05/02/2008 |
| Institutional Review Board | #TX-24 | Establishes an Institutional Review Board (IRB) to review and approve research activities at MSH involving or affecting hospital patients | 07/13/2007 |
| Interpreter Services | #TX-20 | Guidelines for intrepreter services for non-English or limited English speaking patients, or for a patient with a hearing impairment | 08/28/2006 |
| Intra-Campus Transfers | #TX-08 | Transfer of patients between treatment programs | 08/21/2006 |
| #TX-26 | To ensure appropriate review and oversight of non-standard treatment interventions proposed by clinical staff at Montana State Hospital. |
11/30/2005 | |
| Pastoral Services | #TX-09 | Meeting spiritual and religious needs of patients | 09/11/2006 |
| Patient Assessment | #TX-10 | General policy regarding patient assessment procedures | 11/17/2004 |
| Patient Gift Giving | #TX-28 | General policy to address issues related to buying, selling, trading, or gift giving | 08/15/2007 |
| Patient Socio-Sexual Behavior | #TX-11 | Patient sexual behavior | 08/04/2003 |
| Patient Treatment Plan | #TX-12 | Procedure for development and implementation of patient treatment plans | 01/14/2008 |
| Patients' Allocated Monthly Spending Allowance | #TX-19 | To provide guidelines for patients regarding utilization of their financial resources | 09/01/2007 |
| Self-Mutilative Precautions | #TX-13 | Guidelines for prevention of deliberate self-inflicted injuries | 03/30/2007 |
| Suicide Precautions | #TX-14 | Suicide precautions | 01/25/2008 |
| Treatment and Positional Supports | #TX-15 | Use of supportive and treatment restraints | 08/22/2006 |
| Unauthorized Leave Precautions | #TX-23 | Standard procedures for use of unauthorized leave precautions. | 03/30/2007 |
| Use of Seclusion and Restraint | #TX-16 | Use of seclusion and restraint interventions | 03/20/2006 |
Page last updated: 05/09/2008
