| Procedure Log | |||||||
| Last Update: 5/4/04 | |||||||
| *Procedures in yellow have been discontinued. | |||||||
| CHANGE LEGEND: Standards Update, Minor Change/Typo, Rework Procedure, Discountinued, Title Change, New Procedure | |||||||
| Procedure | Location | Origin Date | Change | Appr. Date | Upload Date | Version # | Contact |
| Absence Request/Report Form | 4/2/1987 | D | 4/23/1998 | 4/28/1998 | 4 | S. Orioli | |
| Abuse and/or Neglect Assessment Criteria | v2c3sB | 6/7/1999 | M | 11/5/2002 | 12/16/2002 | 5 | G. Gigax |
| Abuse and/or Neglect Assessment Responsibilities | v2c3sB | 6/7/1999 | M | 11/5/2002 | 12/16/2002 | 5 | G. Gigax |
| Abuse/Neglect/Exploitation Definitions | v2c1sC | 10/30/1991 | M | 10/1/2002 | 12/16/2002 | 8 | M. Moran |
| Abuse/Neglect/Exploitation Investigations | v2c1sC | 3/26/1997 | D | 6/6/2000 | 9/28/2000 | 3 | M. Moran |
| Access to Open Record Request form | v4 | 9/27/2002 | N | 4/1/2003 | 4/14/2003 | 2 | A. Oren |
| Accountability for Equipment | v1c5sA | 4/5/2002 | M | 8/2/2002 | 8/22/2002 | 2 | G. Herrejon |
| Accounting for Disclosing Patient Information | v2c1sE | 10/24/2002 | M | 3/26/2004 | 4/8/2004 | 2 | A. Oren |
| Accounts Payable | v1c3sA | 4/1/1988 | M | 7/2/2002 | 8/22/2002 | 8 | E. Williams |
| Accounts Receivable | v1c3sA | 4/1/1988 | M | 7/2/2002 | 8/22/2002 | 9 | E. Williams |
| Activity Therapy Food Preparation and Service | v1c6sC | 7/21/1988 | D | 10/4/1999 | 10/4/1999 | 6 | J. Norlund |
| Activity Therapy Kitchen Maintenance | v1c6sC | 7/21/1988 | D | 10/4/1999 | 10/4/1999 | 6 | J. Norlund |
| Acuity | 11/14/1997 | D | 4/14/2000 | 5/8/2000 | 2 | A. Mackey | |
| Addressograph Card | v2c2sB | 2/7/1991 | M | 1/8/2004 | 2/6/2004 | 7 | G. Gigax |
| Administration Emergency Preparedness | v3c2sD | 11/6/1991 | M | 1/7/2003 | 3/24/2003 | 7 | L. Henry |
| Administration Fire Plan | v3c3sB | 10/31/1991 | M | 2/4/2003 | 3/26/2003 | 7 | L. Henry |
| Administrative Alert form | v4 | 8/1/1997 | M | 4/1/2003 | 4/14/2003 | 7 | D. Matthews |
| Administrative Alert-After Hours/Weekends | v1c7sB | 8/1/1997 | M | 10/1/2002 | 12/16/2002 | 6 | D. Matthews |
| Administrative and Medical Clearance | v2c2sB | 8/15/2000 | D | 1/16/2001 | 3/8/2001 | 2 | G. Gigax |
| Administrative and Medical Clearance form | v4 | 8/15/2000 | D | 1/16/2001 | 3/8/2001 | 2 | G. Gigax |
| Administrative Conference Room Scheduling | 2/18/1987 | D | 7/3/1997 | 7/28/1997 | 5 | L. Henry | |
| Administrative Leadership Hospital Process Review | v5c1sA | 2/26/1999 | D | 8/1/2000 | 9/14/2000 | 3 | D. Quick |
| Administrative Library | v1c8 | 10/31/1991 | D | 5/2/2000 | 8/23/2000 | 5 | D. Quick |
| Administrative Policies | v5c2 | 10/31/1991 | M | 1/8/2002 | 3/14/2002 | 4 | D. Quick |
| Administrative Policy and Procedure Review | 10/31/1991 | D | 2/26/1999 | 2/27/1999 | 6 | D. Quick | |
| Administrative Request for Court-Ordered Services | v4 | 8/15/1988 | M | 4/1/2003 | 4/14/2003 | 7 | S. Foster |
| Admission History and Physical - Initial Psychiatric Examination | v2c3sA | 2/28/1991 | M | 11/5/2002 | 12/16/2002 | 12 | R. Varner |
| Admission History and Physical and Psychiatric Evaluation | 2/28/1991 | D | 3/5/1999 | 3/28/1999 | 6 | R. Varner | |
| Admission to Inpatient Unit from Outpatient Services | v2c2sC | 7/9/1998 | M | 1/8/2004 | 2/6/2004 | 5 | G. DeJean |
| Admissions | v2c2sA | 6/20/1991 | D | 10/4/1999 | 10/4/1999 | 5 | G. Gigax |
| Adult Patient Care and Treatment Rights | v2c1sD | 1/15/1987 | M | 10/1/2002 | 12/16/2002 | 9 | M. Moran |
| Adult Patient Personal Rights and Confidentiality | v2c1sD | 1/15/1987 | M | 10/1/2002 | 12/16/2002 | 9 | M. Moran |
| Adult Patient Special Rights | v2c1sD | 1/15/1987 | M | 10/1/2002 | 12/16/2002 | 9 | M. Moran |
| Advance Directives | v2c2sB | 2/20/1992 | M | 1/8/2004 | 2/6/2004 | 12 | J. Gunn |
| Advance Directives form | v4 | 2/20/1992 | M | 4/1/2003 | 4/14/2003 | 10 | J. Gunn |
| Adverse Weather Response | v3c2sA | 11/6/1991 | M | 1/7/2003 | 3/24/2003 | 8 | T. Sikorski |
| Advocacy, Inc. Access to Patients | v2c1sB | 6/23/1995 | M | 10/1/2002 | 12/16/2002 | 6 | M. Moran |
| After Hour Warrant Applications | v2c2sB | 12/4/2000 | M | 1/8/2004 | 2/6/2004 | 3 | G. Gigax |
| Aftercare Referral Summary | 6/20/1991 | D | 10/4/1996 | 10/28/1996 | 3 | D. Morgan | |
| Age-Appropriate Toys | 10/3/2000 | D | 5/14/2003 | 5/19/2003 | 2 | A. Mackey | |
| Agency Staff - Orientation and Evaluation | 9/30/1994 | M | 5/14/2003 | 5/19/2003 | 6 | A. Mackey | |
| Alleged Victims of Abuse | 9/30/1994 | D | 7/17/1997 | 7/26/1997 | 2 | A. Mackey | |
| Ambulance Services | v3c2sA | 9/14/1992 | M | 1/7/2003 | 3/24/2003 | 7 | A. Mackey |
| Ancillary Services | 6/20/1991 | D | 8/5/1997 | 8/28/1997 | 3 | A. Mackey | |
| Annual Operating Budget | v1c3sB | 4/1/1988 | M | 7/2/2002 | 8/22/2002 | 8 | E. Williams |
| Anti-Infective Order Form | 6/20/1991 | D | 7/19/1996 | 7/29/1996 | 3 | D. Winkler | |
| Anti-Infective Utilization Review | 6/20/1991 | D | 7/19/1996 | 7/29/1996 | 3 | D. Winkler | |
| Application -Emergency Detention-Sec 28(a) (A20) | v4 | 12/4/2000 | M | 4/1/2003 | 4/14/2003 | 3 | J. Gunn |
| Application for Modification - Inpatient to Outpatient or Change of Programs | v4 | 8/15/1988 | M | 4/1/2003 | 4/14/2003 | 6 | S. Foster |
| Approved Abbreviations and Symbols for Charting | v4 | 2/28/1991 | R | 7/14/2003 | 7/15/2003 | 12 | R. Varner |
| Assent to Consideration of ECT | v4 | 6/20/1991 | D | 9/12/2001 | 9/21/2001 | 6 | R. Varner |
| Assignment for Admission | 1/6/1987 | D | 5/14/2003 | 5/21/2003 | 6 | A. Mackey | |
| Attendance and Punctuality | 4/23/1998 | D | 1/28/2000 | 1/28/2000 | 4 | S. Orioli | |
| Attendance and Punctuality Expectations | 4/28/1998 | D | 11/5/1999 | 11/8/1999 | 2 | S. Orioli | |
| Attendance and Punctuality Guidelines | 4/11/1991 | D | 4/23/1998 | 4/23/1998 | 3 | S. Orioli | |
| Attendance and Punctuality Incentive Program | 4/23/1998 | D | 11/5/1999 | 11/8/1999 | 2 | S. Orioli | |
| Attendance Award Plan | 4/28/1998 | D | 12/21/2001 | 6/21/2002 | 6 | S. Orioli | |
| Attendance of HCPC Staff | 1/30/1997 | D | 2/22/1999 | 2/26/1999 | 2 | S. Orioli | |
| Attending Physician Changes | v2c2sB | 1/5/1989 | M | 1/8/2004 | 2/6/2004 | 10 | R. Varner |
| Attending Physician's Tasks | v2c6 | 4/20/2001 | M | 5/6/2003 | 5/6/2003 | 2 | P. Averill |
| Authorization to Disclose Patient Information form | v4 | 4/22/1999 | M | 4/1/2003 | 4/14/2003 | 7 | G. Gigax |
| Authorization to Release Medical Record Information | v4 | 2/19/2002 | R | 4/8/2003 | 4/10/2003 | 2 | J. Carter-Smith |
| Bedpans/Urinals/Fireman's Caps | 10/1/1991 | M | 5/14/2003 | 5/19/2003 | 4 | A. Mackey | |
| Behavioral Objectives | v5c1sB | 10/4/1999 | M | 6/3/2003 | 6/9/2003 | 5 | S. Orioli |
| Billing and Financial Obligations | v2c2sB | 11/30/1993 | M | 1/8/2004 | 2/6/2004 | 8 | E. Williams |
| Blood Culture Collection | 6/1/1988 | M | 4/7/2003 | 4/7/2003 | 7 | A. Mackey | |
| Blood or Body Fluid Exposures | 12/4/1987 | D | 10/4/1999 | 10/4/1999 | 6 | S. Parnell | |
| Blood or Body Fluid Spills | 12/4/1987 | D | 10/4/1999 | 10/4/1999 | 6 | S. Parnell | |
| Blood Transfusions | v1c6sB | 12/1/1986 | M | 8/6/2002 | 8/22/2002 | 9 | S. Parnell |
| Blue Card Psychiatric Technicians | 2/23/1995 | M | 5/14/2003 | 5/19/2003 | 3 | A. Mackey | |
| Bomb Threat Report form | v4 | 11/6/1991 | M | 4/1/2003 | 4/14/2003 | 8 | T. Sikorski |
| Bomb Threat/Terrorism Response | v3c2sA | 11/6/1991 | M | 1/7/2003 | 3/24/2003 | 7 | T. Sikorski |
| Brain Imaging Request | v4 | 9/9/1993 | M | 4/1/2003 | 4/14/2003 | 7 | R. Varner |
| Breakdown or Accident (UTHCPC Vehicles) | v1c5sB | 1/17/1997 | M | 8/6/2002 | 8/22/2002 | 5 | G. Herrejon |
| Brief Admission/Transfer Form | 4/4/1991 | D | 12/13/2001 | 12/20/2001 | 5 | A. Mackey | |
| Brief Initial Psychiatric Examination | v4 | 9/18/2002 | N | 4/1/2003 | 4/14/2003 | 2 | N. Gruber |
| Brief Psychiatric Rating Scale | v2c2cC | 12/8/1995 | D | 6/6/2000 | 9/28/2000 | 4 | D. Madrigal |
| Budget Modification Process | v1c3sB | 6/4/1993 | M | 7/2/2002 | 8/22/2002 | 6 | E. Williams |
| Budget Modification Request form | v4 | 6/4/1993 | M | 4/1/2003 | 4/14/2003 | 7 | E. Williams |
| Building Services Emergency Preparedness | 11/6/1991 | D | 7/7/1997 | 7/29/1997 | 3 | T. Sikorski | |
| Cardiopulmonary Resuscitation Certification | v1c2sB | 6/17/1991 | M | 7/2/2002 | 8/22/2002 | 8 | A. Tryals |
| Cardiopulmonary Resuscitation Certification | 6/17/1991 | D | 10/3/2000 | 10/4/2000 | 6 | A. Mackey | |
| Cardiopulmonary Resuscitation Evaluation Record | 12/1/1986 | D | 7/30/1997 | 7/30/1997 | 5 | A. Mackey | |
| Care of Patients Process (TX) | v5c2 | 10/4/1999 | M | 6/3/2003 | 6/9/2003 | 4 | G. Gigax |
| Case Management | v2c2sF | 6/20/1991 | D | 6/6/2000 | 9/28/2000 | 5 | B. Dybala |
| Cases Involving Property Damage | v3c5sD | 8/10/1995 | M | 2/4/2003 | 3/26/2003 | 6 | L. Moore |
| Categorization of Patients for Evacuation | v3c2sB | 11/6/1991 | M | 1/7/2003 | 3/24/2003 | 7 | T. Sikorski |
| Centrifuge | 4/7/2003 | N | 4/7/2003 | 4/7/2003 | 1 | A. Mackey | |
| Certificate of Least Restrictive Alternative form | v4 | 8/15/1988 | M | 4/1/2003 | 4/14/2003 | 5 | S. Foster |
| Certificate of Least Restrictive Alternative Treatment | v2c5 | 8/15/1988 | M | 12/16/2002 | 3/19/2003 | 5 | S. Foster |
| Certificate of Medical Examination - Modification to Inpatient - Section 53 | v4 | 8/15/1988 | M | 4/1/2003 | 4/14/2003 | 6 | S. Foster |
| Certificate of Medical Examination - Modification to Outpatient - Section 53 | v4 | 8/15/1988 | M | 4/1/2003 | 4/14/2003 | 5 | S. Foster |
| Certificate of Medical Examination with OPC - Extended - Section 33 | v4 | 8/15/1988 | M | 4/1/2003 | 4/14/2003 | 5 | S. Foster |
| Certificate of Medical Examination with OPC - Section 3.03 - Chemical Dependency | v4 | 12/3/1989 | M | 4/1/2003 | 4/14/2003 | 6 | S. Foster |
| Certificate of Medical Examination with OPC - Temporary - Section 33 | v4 | 8/15/1988 | M | 4/1/2003 | 4/14/2003 | 7 | S. Foster |
| Certificate of Return - Application and Affidavit to Magistrate | v4 | 10/24/2002 | N | 4/1/2003 | 4/14/2003 | 2 | J. Gunn |
| Certificate of Return - To Any Health or Peace Officer in the State of Texas | v4 | 8/15/1988 | R | 4/1/2003 | 4/14/2003 | 8 | J. Gunn |
| Changing Tracheostomy Ties | 11/16/1990 | D | 10/2/2001 | 10/11/2001 | 6 | S. Parnell | |
| Chaplain Assessment/Services | v2c3sC | 6/20/1991 | M | 11/5/2002 | 12/16/2002 | 7 | S. Hodges |
| Charge Description Master Update | v4 | 10/4/1999 | M | 4/1/2003 | 4/14/2003 | 4 | E. Williams |
| Chart Checks | 9/18/1998 | M | 9/25/2003 | 9/29/2003 | 5 | A. Mackey | |
| Chemical Dependency Addendum | 2/28/1991 | D | 6/21/1996 | 6/26/1996 | 3 | D. Morgan | |
| Child and Adolescent Admission Criteria | v2c2sA | 10/31/1991 | M | 1/8/2004 | 2/6/2004 | 11 | G. Gigax |
| Child and Adolescent Free Use Therapy Room | 7/2/1993 | D | 7/30/1997 | 7/30/1997 | 3 | J. Gunn | |
| Child and Adolescent Open Seclusion | 6/28/1993 | D | 7/30/1997 | 7/30/1997 | 3 | J. Gunn | |
| Child and Adolescent Psychosocial Assessment Dictation Format | 2/28/1991 | D | 6/21/1996 | 6/26/1996 | 3 | D. Morgan | |
| Child/Adolescent Admission Assessment Addendum | 1/14/1994 | D | 6/21/1996 | 6/26/1996 | 2 | D. Morgan | |
| Classes of Medication Requiring Consent | v2c3sH | 2/17/1994 | M | 11/5/2002 | 12/16/2002 | 10 | D. Winkler |
| Cleaning a Tracheostomy | 11/16/1990 | D | 11/5/2002 | 12/16/2002 | 7 | S. Parnell | |
| Cleaning a Tracheostomy Ties | 11/16/1990 | D | 11/5/2002 | 12/16/2002 | 7 | S. Parnell | |
| Cleaning and Disinfecting a Blood or Body Fluid Spill | v1c6sD | 12/4/1987 | M | 10/6/2003 | 10/6/2003 | 10 | S. Parnell |
| Cleaning Catheter and Urinary Meatus | v2c3sI | 11/16/1990 | M | 11/5/2002 | 12/16/2002 | 8 | S. Parnell |
| Clinical Chain of Command | 1/11/1988 | D | 7/16/1997 | 7/30/1997 | 5 | D. Morgan | |
| Clinical Services Emergency Management Plan | v4 | 12/16/2002 | M | 12/16/2002 | 1/30/2003 | 1 | S. Grice |
| Clinical Social Services | v2c2sF | 6/20/1991 | D | 10/4/1999 | 10/4/1999 | 4 | J. Norlund |
| Clinical Timeout | 2/21/1997 | M | 6/17/2003 | 6/17/2003 | 3 | A. Mackey | |
| Clinical Use of Electroconvulsive Therapy (ECT) | v2c3sC | 4/4/1991 | D | 10/4/1999 | 10/4/1999 | 4 | R. Varner |
| Closed Circuit Telecasting | v2c3sC | 9/12/2001 | N | 11/5/2002 | 12/16/2002 | 2 | S. Foster |
| Clozapine Therapy | v2c3sF | 12/15/1991 | M | 11/5/2002 | 12/16/2002 | 8 | D. Winkler |
| Code Blue Drill Policy | v1c2sB | 4/14/2000 | M | 4/1/2003 | 4/9/2003 | 5 | A. Mackey |
| Code Blue Evaluation form | v4 | 4/14/2000 | M | 4/1/2003 | 4/9/2003 | 3 | A. Mackey |
| Code Blue Medical Emergency Documentation Record | v4 | 4/8/2003 | N | 4/8/2003 | 4/9/2003 | 1 | A. Mackey |
| Code of Organizational Ethics | v4 | 2/3/2001 | M | 9/25/2003 | 9/25/2003 | 3 | P. Averill |
| Combative/Destructive Precautions | 9/13/1992 | M | 5/14/2003 | 5/19/2003 | 8 | A. Mackey | |
| Committees (PI Plan) | v1c7sA | 4/18/1988 | D | 5/2/2000 | 1/9/2001 | 11 | H. Greenlee |
| Communicable Disease Exposure of Transporters | 1/16/1990 | D | 10/4/1999 | 10/4/1999 | 5 | S. Parnell | |
| Communication of Patient Rights | v2c1sD | 4/29/1994 | M | 10/1/2002 | 12/16/2002 | 6 | M. Moran |
| Communications | v2c1sA | 6/20/1991 | D | 10/4/1999 | 10/4/1999 | 4 | G. Gigax |
| Communications Department Emergency Preparedness | v3c2sD | 11/6/1991 | D | 10/2/2001 | 10/9/2001 | 6 | G. Gigax |
| Community Admissions to Outpatient Services | v2c2sC | 7/9/1998 | R | 10/1/2002 | 12/16/2002 | 5 | G. DeJean |
| Competence Assessment | 10/13/1991 | D | 10/3/2000 | 10/4/2000 | 5 | A. Mackey | |
| Competency Plan | 2/23/1994 | M | 6/12/2003 | 6/17/2003 | 4 | A. Mackey | |
| Competency Requirements | v1c1sC | 8/31/1994 | M | 6/4/2002 | 6/5/2002 | 6 | A. Tryals |
| Completing the Competency Documentation Form | v5c1sB | 10/4/1999 | M | 6/3/2003 | 6/9/2003 | 5 | S. Orioli |
| Confidentiality Cover Sheet | v4 | 2/19/2002 | N | 4/1/2003 | 4/14/2003 | 2 | J. Carter-Smith |
| Confidentiality Guidelines for Participants in Nursing Peer Review Process form | 9/6/1988 | M | 6/12/2003 | 6/17/2003 | 7 | A. Mackey | |
| Confidentiality of Patient Information | 1/26/1987 | D | 10/4/1999 | 10/4/1999 | 7 | M. Moran | |
| Confidentiality of Records and Files Pertaining to Medical Staff | v1c8sA | 10/14/1994 | M | 10/1/2002 | 12/16/2002 | 7 | L. Henry |
| Consent to Release Information to Referring Court | 9/19/1995 | D | 6/27/1997 | 6/27/1997 | 2 | H. Greenlee | |
| Consent to Treatment with Electroconvulsive Therapy (ECT) | v2c3sF | 4/4/1991 | D | 9/12/2001 | 9/21/2001 | 6 | R. Varner |
| Consent to Treatment with Psychoactive Medication | v2c3sH | 2/17/1994 | M | 11/5/2002 | 12/16/2002 | 10 | A. Mackey |
| Consent to Treatment with Psychoactive Medication form | v4 | 2/17/1994 | M | 4/1/2003 | 4/14/2003 | 11 | A. Mackey |
| Consult for Religiosity | v4 | 9/24/2001 | N | 4/1/2003 | 4/14/2003 | 2 | S. Hodges |
| Contact with an Unknown or Undocumented Substance (Hazardous Materials) | v3c4sC | 11/1/1991 | M | 2/4/2003 | 3/26/2003 | 7 | T. Sikorski |
| Contacting Legal Counsel | 11/12/1986 | D | 7/1/1997 | 7/28/1997 | 6 | D. Small | |
| Continuing Care Summary Form | 6/20/1991 | D | 4/22/1999 | 4/26/1999 | 5 | R. Varner | |
| Continuing Nursing Education - Approval of Educational Activities from Other Organza./Individuals | 1/9/2002 | D | 5/21/2003 | 5/21/2003 | 3 | D. Harris | |
| Continuing Nursing Education - Certificate of Successful Completion | 7/7/1995 | D | 5/21/2003 | 5/21/2003 | 5 | D. Harris | |
| Continuing Nursing Education - Co-Providership Agreement | 7/7/1995 | D | 5/21/2003 | 5/21/2003 | 5 | D. Harris | |
| Continuing Nursing Education - Educational Design Criteria | 7/7/1995 | D | 5/21/2003 | 5/21/2003 | 5 | D. Harris | |
| Continuing Nursing Education - Electronic Record Storage | 1/9/2002 | D | 5/21/2003 | 5/21/2003 | 2 | D. Harris | |
| Continuing Nursing Education - Endorsement of Comme | |||||||