Transcription

Medical OfficePolicy andProcedure ManualCompany Name, Inc.1234 Second Ave.San Diego, CA 92101, USATel: 1. 858.321.1234Fax: 1. [email protected]

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1Medical Office Policy and Procedure ManualRevision HistoryVERSION1.0DATEEDITED BYNOTES

3Medical Office Policy and Procedure ManualContentsIntroduction . 11About Cardiology Medical Group . 11Changes to This Manual . 11Cardiology Medical Group Values . 12Physicians . 13Introducing Your Physicians . 13Physicians’ Hours of Work . 13Locum Arrangements. 13Staff . 15Business Manager Job Description . 15Office Assistant Job Description . 16Immunization . 17Bonding of Employees . 17When the Physician Is Away . 17Continuing Education . 17License Recertification . 18Providing Advice without a License . 18Dating Patients . 18Manual Handling Techniques. 18Patient/Physician Relationship . 21Patient Rights and Responsibilities . 21Complaints. 22Medical Office Facility Standards . 25General Information . 25

4Medical Office Policy and Procedure ManualStaff Room. 25Smoking . 26Checklists . 26Office Visits . 29Appointment Scheduling Guidelines . 29Emergency and Priority Cases. 30Appointment Status Change . 30Appointment Status Change, No Show Policy . 30Appointments for Specialists or Consultant Physicians . 31Checking in Patients . 31New Patient Registration . 32Insurance Validation . 32Patient Emergencies/Triage . 33Calling Patients from the Waiting Room . 34Office Encounter Forms . 35Payment Methods . 36Health Services Information . 37Telephone Evaluation, After Hour Telephone . 37No Show Policy. 38Noncompliant Patients . 39Terminating the Physician-Patient Relationship . 39Consent Policies . 43Consent Policies (with or without Representative) and Minor . 43Refusal of Treatment . 54Emergencies and Consent . 57Prescriptions . 61Refilling Prescriptions . 61Preauthorizing Prescriptions . 62

5Medical Office Policy and Procedure ManualPrescriptions That Require Prior Authorization . 625-Day Supplies without Prior Authorization . 63Initiating the Prior Authorization Request . 63Requirements for Prior Authorization Review . 63Automated Prior Authorization Approvals . 63Clinical Review Process . 64Denials . 64Maintaining Medicines . 65Narcotic Drug Controls. 66Initiation of Opioid Treatment . 66Evaluation following a 90-Day Period of Usage . 67Pharmaceuticals at the Office . 68Proper Maintenance and Storage of Drugs . 68Cytotoxic Drugs . 69Reporting Violence and Abuse . 71Immunity . 71Guidelines for Assessment . 71Documentation of Abuse. 72Reporting . 73Penalties . 73Physicians Domestic Violence Training . 73Reporting Child Abuse/Neglect . 73Diagnosis . 75Reporting . 75Immunity. 76Penalties . 76Employee Statements . 76Reporting Elder and Dependent Adult Abuse. 76

6Medical Office Policy and Procedure ManualAbuse . 76Physical Abuse . 77Sexual Assault. 77Sexual Abuse . 77Physical Abuse Indicators. 77Fiduciary Abuse . 78Neglect . 78Abandonment . 79Isolation . 79Dependent Adult Abuse . 79Endangered Adults Laws . 81Patient/Office Safety . 85Patient Injuries at Cardiology Medical Group . 85Office Security . 90Office Data Security . 90General Guidelines . 90E-mail Communication . 91Red Flag Rule Identity Theft Compliance Program . 91OSHA Resources . 94OSHA 300 Log . 94Workplace Violence Prevention . 95Medical Services and First Aid . 95Emergency Plan Procedures. 97General Emergency, Disaster, and Safety Procedures . 97Emergency Plans. 97Evacuation . 97Transfer of Patient to Ambulance . 98Earthquake . 101

7Medical Office Policy and Procedure ManualFire (Code Red). 102Power Outage . 104Bomb Threat (Code Purple) . 104Cardiac Arrest/Medical Emergency (Code Blue) . 106Flood/Water Leak Emergency (Code Yellow) . 107Gaseous Leak or Gas Explosion Nearby (Code Yellow) . 107Hold up/Violent Person (Code Black) . 108Infection Control . 109Universal Precautions . 109Sterilization . 112Steam Sterilization. 113Cold Sterilization . 114Gas Sterilization . 115Hazard Communication to Staff . 115Container Labeling . 115Safety Data Sheets (SDS) . 115Employee Information and Training . 116Hazardous Non-Routine Tasks . 117Multi-Employer Work Places. 117List of Hazardous Chemicals . 118Rights of Employees. 118HCS Pictograms and Hazards . 120Preventing Transmission Respiratory Infection . 121Hazardous Waste . 121Sharps . 121Spills of Blood and Other Bodily Substances . 122Disposal of Patient Specimens . 122Waste Collection . 123

8Medical Office Policy and Procedure ManualNeedlestick and Sharps Injuries. 124Treating the Contamination Site . 124Reporting the Incident . 124Medical Records . 127Requirements and Standards . 127Advance Directives . 130Information Confidentiality and Access to Records . 131Releasing Confidential Records . 134Confidentiality Agreement for Physician Office Employees . 136Model Letter to a Patient Who Requests Withholding of Information from Disclosure138Authorization to Transfer Medical Records . 140Authorization for Release of Medical Information . 142Privacy Complaints . 143Mitigation of Privacy Breaches . 144Review of Test Results . 149Scanning Medical Records and Documents. 150Limited Data Set Records . 150Data Use Agreements . 152Creating the Limited Data Set . 152Responsibility for Data Use Agreements . 153Tracking/Accounting . 153Accounting of Disclosures . 153Release of Information under Permissive Disclosures . 156Disclosure to Families and Loved Ones . 157Disclosing Mental Health Information . 157Mandatory Disclosures . 159HIV Consent and Reporting . 159Reportable Diseases . 159

9Medical Office Policy and Procedure ManualResponding to Law Enforcement . 160Response to Private Investigators. 162De-identification of Records . 162Chart Review Protocol . 164Final Evaluation Types .