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