Policy Manual sample

MDT Home Health Care Agency, Inc. 199 ♦ Blind (unknown source) test performance and resulting ♦ Simulation of test performance with training equipment/materials for waived testing performed infrequently • Demonstrate, via documented written evaluation and/or verbal assessment by supervisor, familiarity of the organization’s policies, procedures, scope of services and patient population needs. • Pursuant to the patient care unit’s scope of services, licensure, expertise and training of clinical staff and frequency of waived testing procedures, the patient care unit manager will determine the frequency of competency evaluation for any waived testing procedures performed on that unit. • Any test listed on the Waived Testing Index will be specifically detailed in written policy and procedure format: • The policy and procedure will indicate the extent to which the test results are to be used in the care of the patient, noting whether the result is of screening value only or if the result is to be deemed definitive for diagnosis and treatment. • The policy and procedure will indicate whether the nurse is to provide treatment/ intervention, based on the test result and pursuant to a physician’s order or in accordance with an approved protocol. • The policy and procedure will indicate documentation requirements in the medical record. • The policy and procedure will indicate the type, frequency and extent of quality control checks to be conducted for the specific waived test procedure. • The policy and procedure will be kept current and will be readily available. The policy and procedure for the specific test will include, but may not be limited to:  Specimen collection, identification and required labeling, as appropriate  Specimen preservation, as appropriate  Instrument calibration  Quality control and remedial action  Equipment performance evaluation  Test performance