Policies and Procedures

click below   1: ETHICS, RIGHTS AND RESPONSIBILITIES
1001   Patient Rights and Responsiblities
    TJC RI.01.01.01, RI.01.01.03, RI.01.02.01, RI.01.03.01, RI.01.03.05, RI.01.04.01, RI.01.05.01, RI.01.06.03, RI.01.07.01; MCGHI 14.87
1002   Informed Consent
    TJC RI.01.03.01; MCGHI 14.67, 14.68
1003   Advance Directives
    TJC RI.01.05.01; MCGHI 14.53
1004   Do Not Resuscitate (DNR)
    TJC RI.01.02.01, RI.01.05.01; MCGHI 14.91
1005   Confidentiality of Information - General Issues
    MCGHI 1.04, 6.05, 6.11
1006   Patient Rights and Responsiblities for Pain Management
1007   Blood/Blood Component - Informed Consent
    TJC RI.01.01.01; MCGHI 14.69
1008   Blood/Blood Component Transfusion Consent Form
    TJC RI.01.03.01
1009   Refusal of Blood/Blood Component Transfusion
    TJC RI.01.02.01
1010   Refusal to Permit Blood/Blood Component Transfusion Form
    TJC RI.01.02.01
1011   Staff Rights and Ethical Dilemmas in Patient Care
    TJC LD.04.02.03; MCGHI 4.90.09
click below   2: PROVISION OF CARE, TREATMENT AND SERVICES
2001   Rules and Regulations
    TJC PC.03.01.03, PC.03.01.05, PC.03.01.07, EC.02.04.03, IC.02.01.01, LD.04.01.05; ASA Guidelines for the Ethical Practice of Anesthesiology
2002   Anesthesia Responsibilities
    TJC PC.03.01.03, PC.03.01.05, PC.03.01.07
2003   Anesthesia Responsibilities for Outpatient Procedures
    TJC PC.03.01.03, PC.03.01.05, PC.03.01.07
2004   Preoperative Testing/Assessment for Inpatients
    TJC PC.03.01.03
2005   Ambulatory Surgery Preoperative Assessment Criteria
    TJC PC.03.01.03
2006   Patient Identification for Clinical Care and Treatment
    NPSG.01.01.01
2007   Preanesthesia Assessment
    TJC PC.03.01.03
2008   Preanesthesia Assessment by CRNA
    TJC PC.03.01.03, MS.03.01.03
2009   ASA Classification System
    TJC PC.03.01.03
2010   Care of the Latex Sensitive Patient
    TJC PC.01.02.01, PC.03.01.01; MCGHI 4.70.03
2011   Latex Allergy - Patient Questionnaire
    TJC PC.01.02.01, PC.03.01.01
2012   Latex and Non-Latex Alternatives
2013   Surgical Site Identification
    TJC UP.01.01.01, UP.01.02.01, UP.01.03.01; MCGHI 14.112
2014   Invasive Procedure Site Identification
    TJC UP.01.01.01, UP.01.02.01, UP.01.03.01
2015   Pre- and Post-Anesthesia Evaluation Policy
    TJC PC.03.01.01, PC.03.01.03, PC.03.01.07
2016   Pre- and Post-Anesthesia Evaluation Form
    TJC PC.03.01.01, PC.03.01.03, PC.03.01.07
2017   Assessment Prior to Induction of Anesthesia/Sedation
    TJC PC.03.01.03
2018   Anesthesia Awareness
    TJC PC.03.01.01, PC.03.01.03
2019   Guidelines for Administration of Anesthesia
    TJC PC.03.01.01, PC.03.01.03
2020   Intraoperative Anesthesia Care
    TJC PC.03.01.05
2021   Completion of Anesthesia Record
    TJC PC.03.01.03, PC.03.01.05, PC.03.01.07, RC.02.01.03; CompuRecord Information; Signature Policy for MCGHI Anesthesia Service
2022   Anesthesia Record Form
    TJC PC.03.01.03, PC.03.01.05, PC.03.01.07, RC.02.01.03
2023   Patient Positioning
    TJC PC.02.01.01
2024   Acquisition, Identification and Administration of Blood Products
    TJC PC.02.01.01
2025   Pain Assessment in Children
    TJC PC.01.02.07
2026   Assessment Pain Scale
    TJC PC.01.02.07
2027   Pain Scale Examples
    TJC PC.01.02.07
2028   Behavioral-Physiological Pain Scale for Non-Verbal or Pre-Verbal Patients
    TJC PC.01.02.07
2029   Postoperative Anesthesia Care
    TJC PC.03.01.07
2030   Sedation
    TJC PC.03.01.01, PC.03.01.03, PC.03.01.05, PC.03.01.07
2031   Sedation Monitoring Form
    TJC PC.03.01.01, PC.03.01.03, PC.03.01.05, PC.03.01.07, RC.02.01.03
2032   Cardiopulmonary Resuscitation in the Operating Room
    TJC PC.02.01.01, PC.03.01.01, MM.03.01.03
2033   Patient Defibrillation
    TJC PC.02.01.01
2034   Emergency Equipment in the PACU
    TJC PC.03.01.01, MM.03.01.03
2035   Criteria for Notifying Anesthetist
    TJC PC.03.01.07
2036   Surgeon/Anesthetist Discharge Responsibilities
    TJC PC.03.01.07; MCGHI 13.59, C.21.0
2037   Management of Patient with Malignant Hyperthermia
    TJC PC.03.01.05. PC.03.01.07
2038   Malignant Hyperthermia Cart
    TJC PC.03.01.05. PC.03.01.07
2039   Capnography
    TJC PC.03.01.05. PC.03.01.07
2040   Patients with Sleep Apnea
    TJC PC.01.02.01, PC.01.02.03, PC.01.03.01, PC.02.01.01, PC.03.01.01, PC.03.01.05, PC.03.01.07
2041   Placement of Epidural Blood Patch (EBP)
    TJC PC.01.02.01
click here 3: MEDICATION MANAGEMENT
3001 Security of Medications - Anesthesia Carts
TJC MM.03.01.01
3002 Concentrated Electrolyte Solutions and Other Drug Concentrations
TJC MM.03.01.03
3003 Emergency Crash Carts
TJC MM.03.01.03
3004 Emergency Crash Cart Security and Accountability
TJC MM.03.01.03
3005 Emergency Medications
TJC MM.03.01.03
3006 Emergency Medications List
TJC MM.03.01.03
3007 Telephone, Verbal and Written Orders for Medication
TJC MM.04.01.01, NPSG.02.02.01; MCGHI 13.63
3008 Medication and Solution Administration in the OR
TJC NPSG.03.04.01
3009 Pediatric Dosing - General Guidelines
TJC MM.06.01.01
3010 Administration of Preoperative Antibiotics
TJC MM.06.01.01
3011 Adverse Drug Reaction Reporting
TJC MM.07.01.03, PI.01.01.01
3012 Adverse Drug Reaction Reporting Form
TJC MM.07.01.03, PI.01.01.01
3013 Potential Adverse Drug Reaction Form
TJC MM.07.01.03, PI.01.01.01
3014 Medication Inadvertent Incident Report Form
TJC MM.07.01.03, PI.01.01.01
3016 Medication Error Analysis Tool
TJC MM.07.01.03, PI.01.01.01, PI.02.01.01
click here 4: SURVEILLANCE, PREVENTION AND CONTROL OF INFECTION
4001 Infection Control
TJC IC.01.05.01, IC.02.01.01; MDRO (multiple-drug resistant organism) Task Force Update Report of Annual Risk Assessment 7-2009 (includes drafts of ICM 10.0 Infection Prevention and Control Authority Statement; ICM 4.3 Contact Precautions; ICM 5.0 Prevention and Control of Multiple Drug-Resistant Organisms (MDROs); ICM 4.8 Transmission-Based Precautions: Initiation and Discontinuance; ICM 2.0 Infection Prevention and Control Authority Statement; and NPSG 07.03/01 (MDRO) Gap Analysis
4002 Standard Precautions
TJC IC.02.01.01, CDC Recommendations
4003 Asepsis
TJC IC.02.01.01
4004 Hand Hygiene - CDC Recommendations
TJC IC.01.04.01, IC.02.01.01, NPSG.07.01.01, CDC Guidelines
4005 Attire in the Operating Room
TJC IC.02.01.01
4006 Waterless, Scrubless, Brush-Free Surgical Hand Rub Antiseptic
TJC IC.02.01.01
4007 Gowning and Gloving Technique
TJC IC.02.01.01, CDC Guidelines
4008 Patient Skin Prep
TJC IC.02.01.01
4009 Transmission-Based Precautions (Isolation Precautions)
TJC IC.02.01.01, CDC Guidelines
4010 Sharps Precautions
TJC IC.01.04.01, IC.02.01.01, IC.02.02.01, OSHA Regulations
4011 Sharps Injury Protection Plan
TJC IC.01.04.01, IC.02.01.01, IC.02.02.01, OSHA Regulations
4012 Sharps Injury Log
TJC IC.02.01.01, OSHA Regulations
4013 Definition of Biohazardous Waste
TJC IC.02.01.01, EC.02.02.01, OSHA Regulations
4014 Visitor Control
TJC IC.02.01.01
click here 5: IMPROVING ORGANIZATION PERFORMANCE
5001 Department of Anesthesiology Performance Improvement Plan
TJC PI.01.01.01, PI.02.01.01, PI.03.01.01, LD.03.05.01, LD.04.04.01; MCGHI 13.65, 14.77, Mission Statement, Responsibility Matrix for Performance Improvement, Pain Management Performance Improvement
5002 Performance Improvement Activities
TJC PI.01.01.01, PI.02.01.01, PI.03.01.01
5003 Anesthesia Committee PI Monitoring and Evaluation Plan
TJC PI.01.01.01, PI.02.01.01
5004 Anesthesia Committee PI Trending Sheet
TJC PI.01.01.01, PI.02.01.01
5005 Anesthesia Committee PI Outcome Evaluation
TJC PI.01.01.01, PI.02.01.01, PI.03.01.01
5006 Anesthesia Committee PI Volume Measures/Statistics
TJC PI.01.01.01
5007 Performance Improvement Quarterly Report Form
TJC PI.01.01.01
5008 Anesthesia Generic Screen Form
TJC PI.01.01.01
5009 Incident Reporting
TJC PI.01.01.01, PI.03.01.01; MCG 3.0.03
5010 Performance Improvement Indications and Notification Form - Surgery - Anesthesia - PACU
TJC PI.01.01.01
5011 Sentinel Event
TJC LD.04.04.05, PI.03.01.01, NPSG.07.02.01; MCGHI 14.94
click here 6: LEADERSHIP
6001 Scope of Services
TJC LD.03.03.01, LD.04.01.05, LD.04.03.01; ASA The Scope of Practice of Nurse Anesthetists, 2004
6002 Anesthesia Coverage
TJC LD.03.06.01, LD.04.01.05
6003 Anesthesia Coverage - Captured Call
TJC LD.03.06.01, LD.04.01.05
6004 Emergency Service Coverage
TJC LD.03.06.01, LD.04.01.05
6005 Nurse Anesthesia Services Organization and Direction
TJC LD.03.06.01, LD.04.01.07; MCGHI 13.52
6006 Jail Custody Patients
TJC PC.01.01.01; MCGHI 9.59
click here 7: MANAGEMENT OF THE ENVIRONMENT OF CARE
7001 Patient Safety in the Operating Room
TJC EC.01.01.01, EC.02.03.01, EC.02.04.03, EC.03.01.01
7002 Standards for Anesthesia Performance and Maintenance Criteria
TJC EC.01.01.01, EC.02.04.03; MCGHI E.C.6.10, E.C.6.20
7003 Anesthesia Safety
TJC EC.01.01.01, EC.02.04.03
7004 Anesthesia Equipment Safety
TJC EC.02.04.03
7005 Anesthesia Apparatus Check Recommendations
TJC EC.02.04.03
7006 Anesthesia Apparatus Checklist
TJC EC.02.04.03; ASA Recommendations for Pre-Anesthesia Checkout Procedures
7007 Use of Clinical Alarms on Medical Equipment
TJC EC.02.04.03
7008 Stocking and Cleaning Anesthesia Machines
TJC IC.02.01.01 AORN Standards
7009 The Anesthesia Workplace
TJC EC.01.01.01
7010 Fire Safety in an Oxygen Rich Environment - Operating Room
TJC EC.01.01.01, EC.02.03.01
7011 Anesthesia Gas and Nitrogen Storage
TJC EC.01.01.01, EC.02.02.01
7012 Compressed Gas and Oxygen Use
TJC EC.01.01.01, EC.02.02.01
click here 8: MANAGEMENT OF HUMAN RESOURCES
8001 Position Description/Performance Evaluation - Chief CRNA
TJC EC.01.01.01, EC.02.02.01
8002 Performance Evaluation - Population - Specific/Age-Related Competency - Chief CRNA
TJC HR.01.02.01, HR.01.02.07, HR.01.06.01, LD.01.07.01, LD.03.06.01
8003 Annual Competency Clinical Skills Assessment - Chief CRNA
TJC HR.01.06.01, LD.01.07.01
8004 Position Description/Performance Evaluation - Certified Registered Nurse Anesthetist (CRNA)
TJC HR.01.02.01, HR.01.02.07, HR.01.06.01, LD.01.07.01, LD.03.06.01;AANA Scope and Standards for Nurse Anesthesia Practice, 2007;AANA Guidelines for Core Clinical Privileges, 2005;AANA Education of Nurse Anesthetists in the United States;AANA Code of Ethics for the Certified Registered Nurse Anesthetist
8005 Performance Evaluation - Population - Specific/Age-Related Competency -  CRNA
TJC HR.01.06.01, LD.01.07.01
8006 Annual Competency Clinical Skills Assessment - CRNA
TJC HR.01.06.01, LD.01.07.01
8007 Position Description/Performance Evaluation - Surgical Services Pain Management RN
TJC HR.01.02.01, HR.01.02.07, HR.01.06.01, LD.01.07.01, LD.03.06.01
8008 Performance Evaluation - Population - Specific/Age-Related Competency - Surgical Services Pain Management RN
TJC HR.01.06.01, LD.01.07.01
8009 Annual Competency Clinical Skills Assessment - Surgical Services Pain Management RN
TJC HR.01.06.01, LD.01.07.01
8009.1 Physician's Assistant
PPG Job Description; Composite State Board of Medical Examiners 360-5-.03
8009.2 Nurse Anesthetist
ASA Recommended Scope of Practice of Nurse Anesthetists and Anesthesiologist Assistants
8009.3 Psychologist in Pain Management
PPG Job Description
8010 Annual Competency - 2008 Joint Commission National Patient Safety Goals
TJC HR.01.06.01, LD.01.07.01
8011 Educational Responsibilities of the Department of Anesthesia
TJC HR.01.05.03; Description of Department's Education Program
8011.1 Policy and Guidelines for Interactions between Medical College of Georgia School of Medicine with the Pharmaceutical, Biotech, Medical Device, and Hospital and Research Equipment and Supplies Industries
click here 9: MANAGEMENT OF INFORMATION
9001 Legibility of Medical Record Documentation
TJC RC.01.01.01, RC.01.04.01, MM.04.01.01
9002 Documentation Required for a Surgical Case
TJC RC.02.01.01, RC.02.01.03
9003 Documentation and Use of Abbreviations, Acronyms and Symbols
TJC IM.02.02.01, NPSG.02.02.01
9004 Unacceptable Abbreviation and Symbol List
TJC IM.02.02.01, NPSG.02.02.01
9005 Acceptable Abbreviations List
TJC IM.02.02.01
click here 10: MEDICAL STAFF
10001 Organization of the Department of Anesthesiology
TJC MS.03.01.01
10002 Anesthesia Medical Staff Rules and Regulations
TJC MS.01.01.01
10003 a. Duties and Responsibilities of Chief Anesthesiologist
TJC MS.01.01.01, LD.04.01.05
b. Duties and Responsibilities of Medical Director of Pain Management
10004 General Guidelines in the Credentialing and Privileging Process
TJC MS.06.01.05, MS.06.01.05; MCGHI 13.51
10005 Medical Staff Reappointment and Renewal of Clinical Privileges
TJC MS.06.01.05, MS.06.01.07
10006 Anesthesia and Staff Categories
TJC MS.01.05.01
10007 Continuing Medical Education Requirements
TJC MS.12.01.01
10008 Continuing Medical Education Record Form
TJC MS.12.01.01
click here 11: PAIN MANAGEMENT
11001 Admission to Pain Management Program
TJC PC.01.02.07, RI.01.01.01; MCGHI 14.103
11002 Comprehensive Pain Assessment Form
TJC PC.01.02.07
11003 Pain Management Flow Sheet
TJC PC.01.02.07
11004 Discharge from Pain Management Program
TJC PC.01.02.07, PC.03.01.07
11005 Patient Controlled Analgesia (PCA)
TJC PC.01.02.07, MM.04.01.01
11006 Patient Controlled Analgesia - Sample Physician's Orders
TJC PC.01.02.07, MM.04.01.01
11007 Sample Postoperative Epidural Narcotic Continuous Infusion Physician's Orders
TJC PC.01.02.07, MM.04.01.01
11008 PCA Infusion Pump
TJC MM.06.01.01
11009 Nursing Procedure for Intermittent, Continuous and PCA Infusions via Epidural Catheter
TJC PC.01.02.07, MM.06.01.01
11010 PCA Follow-up Visit Form
TJC PC.01.02.07
11011 Pain Management Services Patient Satisfaction Survey - PCA Questionnaire
TJC PI.01.01.01
11012 Not Applicable
11013 Monitoring and Infusion Protocols for Patients Receiving Epidural Analgesia
TJC PC.01.02.07, MM.06.01.01
11014 Epidural Analgesia for Chronic Pain Management - Continuous Infusion
TJC PC.01.02.07, MM.06.01.01
11015 Protocol for the Administration of Epidural Anesthesia for OB Patients
TJC PC.01.02.07, MM.06.01.01
11016 Postoperative Epidural Narcotic (Continuous Infusion Mode)
TJC PC.01.02.07, MM.06.01.01
11017 Epidural Catheter Dressing Changes
TJC PC.02.01.01, IC.02.01.01
11018 Removal of Epidural Catheter
TJC PC.02.01.01
11019 Hypertonic Saline Injection for Neurolysis
TJC PC.01.02.07, PC.02.01.01
11020 Intravenous Local Anesthetic Infusion Protocol
TJC PC.01.02.07
11021 Intravenous Local Anesthetic Infusion Procedure
TJC PC.01.02.07, PC.02.01.01
11022 Lumbar Sympathetic Nerve Block
TJC PC.01.02.07, PC.02.01.01
11023 Phenol for Use in Nerve Blocks
TJC PC.01.02.07, PC.02.01.01
11024 Trigger Point Injection
TJC PC.01.02.07, PC.02.01.01

 

 

 

 

 

 

 

 

 

 

 

 

Revised November 24, 2009ate --> .  Please send comments, suggestions or questions about this page to Susan Dawkins, sdawkins@mcg.edu .