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Document Statement
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To establish a minimum safe standard for Scheduled and Unscheduled Admissions from the MCGHealth Cancer Center to the Medical College of Georgia Hospital.  These Admissions may be determined Emergent or Non-Emergent.  The Attending Physician will determine whether a patient is a candidate for Emergent or Non-Emergent Hospital Admission.
PolicyAmbulatory Care Services
To prevent patient calls to the nurse/physician call lines from being dropped in the gap between closing time for practice sites, and forwarding of calls to physician’s answering service by the Call Center. To provide guidance and consistency for the clinic and Desk Operations staff in call forwarding procedure.  Any practice site closing before 5:30 p.m. will forward the nurse/physician call line(s) directly to the Physician’s Answering Service. The call line(s) will be retrieved from the Physician’s Answering Service and sent back to the Call Center when business hours begin the next morning.
PolicyAmbulatory Care Services
There are instances when the use of a credit card is needed in order to purchase items in a timely manner.  Ambulatory Care Services must implement the use of any credit cards for official use in a manner consistent with institution policies, standard accounting practices, and the existing management structure.  Approval to obtain a credit card must be granted through Ambulatory Care Administration prior to obtaining a card through Finance.  Requests for a card will be reviewed on a case by case basis and require justification to support the need.  If approval for a card is granted, the designated credit card holder must complete required training and follow all appropriate policies and procedures regarding authorized card use.
PolicyAmbulatory Care Services
Practice Site hours of operation are generally 8:00 a.m. - 5:00 p.m., Monday through Friday; however, some Practice Sites may have a need for extended hours to:
1. Complete a patient’s examination/treatment.
2. Finish examining scheduled patients.
3. Complete admission procedures for a patient.
4. Arrange transportation and/or lodging for a patient and/or family member.
PolicyAmbulatory Care Services
1. Patients receiving pain management procedures are to be discharged home in a timely
manner, appropriately and to a safe environment.
2. Patient is informed about side effects, including but not limited to pain, increase in blood
glucose with the use of steroid medications.
PolicyAmbulatory Care Services
To provide a standard procedure for the maintaining, acquisition, cleaning and use and storage of the Rhino-Laryngofiber Scopes in GRTC.
PolicyAmbulatory Care Services
To assure that all adult patients requiring admission through the practice sites are admitted, as soon as possible, to a location that can provide the required monitoring and care.  For patient in the Ambulatory setting waiting for inpatient admissions with an anticipated extended
wait, the Emergency Department (ED) will be contacted to determine the availability to accept patient in the ED Observation Unit (EDOU).
PolicyAmbulatory Care Services
In conjunction with activities by Environmental Services, the Pediatric Practice will provide a clean patient care environment.
PolicyAmbulatory Care Services
To outline nursing responsibilities for administering immunizations in the Pediatrics and
Family Medicine Practice Site.
PolicyAmbulatory Care Services
To facilitate the access to medical records in the Operating Room setting to prevent delays in patient care.  Any Practice Site who schedule and complete pre-op paperwork within the Practice Site will process and send the appropriate pre-operative paperwork to medical records using the procedures outlined below.
PolicyAmbulatory Care Services
To provide a standard procedure for cleaning and maintaining Procedure and Treatment Rooms in the Ambulatory Care Center.  All minor invasive procedures will be done in the designated procedure rooms within the practice sites. The practice sites will develop policy listing which rooms will be designated as treatment/procedure rooms, what procedures may be performed, and what procedures may not be performed in these rooms. Other practice site specific information will be incorporated into practice site policy.
PolicyAmbulatory Care Services
To establish provisions for the sterilization and processing of scopes/equipment in
Ambulatory Care Services that ensures both patient and staff safety.  This policy follows the standards set forth by MCG Health Epidemiology and current CDC guidelines
PolicyAmbulatory Care Services
The Response Urgently Needed (RUN) team is a resource available within Ambulatory Care settings to provide resources that are needed in a timely manner to address the safety needs of patients, visitors, and staff. This policy will define the RUN team, its function and activation within Ambulatory Care Services.

On occasion, there can be patient, family, or staff safety situations within the Ambulatory clinics that require additional resources toappropriately address. These are non-emergent situations that fall outside of a RAT, PET, or CODE 99. The RUN team will also respond to CODE 99 to provide backup and crowd control. Staff should activate the RUN whenever there are non-emergent concerns for the care and safety of a patient, visitor, or staff. If the RUN determines they cannot adequately care for the individual; a higher level of care should be immediately sought.
PolicyAmbulatory Care Services
A list of Organization Wide indicators consisting of, abuse or neglect, nutritional or metabolic needs, skin breakdown, Fall Risk/Functional needs, Discharge needs prior to departure from Practice Site, Behavioral Health Risk, Substance Abuse and follow-up actions for each.
PolicyAmbulatory Care Services
The objective of this protocol is to identify ambulatory patients who are require
investigation/intervention(s) for
  1. Abuse or neglect
  2. Nutritional or metabolic needs
  3. Skin breakdown
  4. Fall Risk/Functional needs/
  5. Discharge needs prior to departure from Practice Site
  6. Behavioral Health Risk
  7. Substance Abuse
During patient encounters in Ambulatory Care Practice Sites, staff and physicians may encounter the above noted patient care issues that are outside the scope of the patient visit but still require documentation and intervention. Such issues will be appropriately investigated and interventions put in place including but not limited to patient/family education, resources, and referrals.
PolicyAmbulatory Care Services
To prevent inappropriate reading material from being placed in patient waiting spaces and exam rooms in Ambulatory Care Services (ACS) Practice sites.  Ambulatory Care Services, with its dedication to excellence in patient and family centered care, acknowledges that the information displayed in any of its public and private areas should be of a wholesome and professional
nature. In addition, attention should be given to the age, wear and tear, and general appearance of all materials displayed in practice site wait spaces in order to reflect an image of excellence. Therefore, materials to be placed in these spaces will be systematically screened and wait spaces will be checked on a daily basis for inappropriate material.
PolicyAmbulatory Care Services
To establish provisions for the sterilization and processing of scopes/equipment in Ambulatory Care Services that ensures both patient and staff safety.  This policy follows the standards set forth by MCG Health Epidemiology and current CDC guidelines
PolicyAmbulatory Care Services
All patients will have the following data entered and/or updated after each clinic visit: current medications, including prescription, over the counter and herbals; allergies; problems and procedures or surgeries. This data will be available for viewing to all other practice settings.
PolicyAmbulatory Care Services
Medical Record (HIMS) – Pre-Op Scanning
PolicyAmbulatory Care Services
Medical Records
Surgical Documents for Scanning
and Filing in PowerChart
Practice Site:
PolicyAmbulatory Care Services