Policy and Procedure Manual

Introduction

• Message from our Clinic Director
• Organizational chart
  

General information for employees

• General information for all employees
• Infection control

General information about the clinic

• About the Internal Medicine Clinic
• Clinic layout
• Call light system

Daily operations

• Opening the clinic
• Same Day Care
• Enhanced Care
• Carolina Access
• Check-in process
• Lipid ordering policy
• Patient registration and demographic verification
• Interpreter Services
• Check-out process
• Policy and Procedure for Coding for E-Prescribing
• Late patient policy letter
• Late patient scripts

Scheduling

• Brief tour of the Amion Scheduling System
• Patient registration and demographic verification
• Unavailable residents
• Scheduling rules
• IMC Pain Service block policy and script
• IMC Pain Service no show note
  

Referrals and visit coordination

• Clinic Support Website (CSW) general information
• Clinic Support Website (CSW) online form protocol
• Phlebotomy referrals
• Ancillary referrals
• Ancillary request policy
• Ancillary scheduling cheat sheet
• Ancillary fax numbers
• Specialty clinic referrals
• Specialty clinics requiring patient to call to schedule appointments
• Patient and Referral Portal Patient Access Manual
• Financial assistance and Billing dispute resolution

Messages

• Phone calls - general instructions
• Telephone messages
• Telephone emergency protocol
• Standing Order for incoming calls and faxes
• Standing Order for WebCIS phone messaging
  • Medication refill requests
  • Prior authorizations
  • Forms
• WebCIS phone message basic action guidelines

• Phone message tip sheet
• Clinic pager responsibility
• Resident vacation coverage

• Processing patient calls for physicians with designated nurse
• Releasing lab results
• Verbal orders

Forms processing

• Distribution of forms for processing
• Guidelines for prior authorizations
• Algorithm for prior authorizations
• Protocol for distribution of resident paperwork
• Release of medical information
• Home Health & Hospice billing policy
  • HH&H billing form
• Durable medical equipment policy
  • DME letter
  • DME order form
• IMC faxform
• Editing/updating charge document

Protocols

• Smoking cessation algorithm
• Safety Alert (helping people find staff)
• Scripts for anonymous callers
• Reporting deaths
• Patientfires
• Narcotic dismissals

Medications

• Medication refills (routine, restricted, and narcotics)
• Standing Order for incoming calls and faxes
• Standing Order for WebCIS phone messaging
• Medication refills requiring physician approval
• Prior authorization policy
• Prior authorization cheat sheet
• Narcotic prescription flowsheet
• Prescription log

Nursing practice standards

• Admissions
• IMC triage
• Triage nurse protocol
• Blood pressure monitoring
• Pap smear collection
• Pap algorithm, followup and tracking
• Pap smear letters
• FOBT standing order
• ASCUS tracking sheet
• Interdermal injections
• Setting up for a Reclast injection
• Late clinic team leader

Immunizations

• Flu vaccine messages and schedule templates
• Influenza and pneumococcal protocol
• Pneumococcal administration procedure
• Influenza and pneumococcal vaccine standing order
• POC A1c and lipids standing order
• Shingles vaccine standing order
• Td and Tdap vaccine standing order
• Zoster/Guardasil waiver form

WebCIS documentation

• Vitals
• Annotations
• Immunizations

Physician practice standards

• Practice standards
  • Visit documentation
  • Verbal orders
  • Critical values
  • Resident coverage for document processing and provider signature
  • Patient lab / test follow-up
• Patient correspondence
• Home Health process for physicians
• Physician clinic schedules and template changes
  
  • Schedules
  • Clinic cancellation
  • Template changes
• Physician leave preparation
• Support staff preparation for physician leave

Visit planners

• About the Visit Planner care management tool  (TO COME)
• Visit Planner prompts for PBAs
• Visit Planner prompts for nurses
• Visit Planner prompts for providers

Screening

• Depression
• Suicidality (phone)
• At Risk Caller Response Outline
• Suicidality (in clinic)
• Suicidality Assessment & Management Algorithm Form
• Suicidality Risk Response outline

• Domestic violence (TO COME)

Medical care for employees

• Policy for obtaining medical care for IMC employees from IMC providers
• Policy to ensure optimal care of the IMC staff