Health Care Policy Manual
| Policy Number | Policy Name | Review Date | Revised Date |
| AD - Administrative | |||
|
I. Organization |
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| AD I-1 | Health Services Mission, Vision, Goals and Objective | 2-2012 | 2-2012 |
| AD I-2 | Health Care Treatment Philosophy | 2-2012 | 2-2012 |
| AD I-3 | Overall Responsibilities | 7-2010 | 10-2008 |
| AD I-4 | Facility Procedures | 8-2010 | 8-2010 |
| AD I-5 | Definitions of Medical Mission | 1-2012 | 4-2008 |
| AD I-6 | Nursing Procedure Manual | 2-2018 | 2-2018 |
| II. Performance Improvement and Risk Management | |||
| AD II-1 | Performance Improvement Plan | 7-2017 | 7-2017 |
| AD II-2 | Health Services Peer Review | 4-2010 | 9-2008 |
| AD II-3 | Medical Statistics and Reports | 4-2010 | 10-2007 |
| AD II-4 | Inmate Injuries (workman's comp) | 4-2010 | 5-2002 |
| AD II-5 | Rescinded | ||
| AD II-6 | Rescinded | ||
| AD II-7 | Internal Medical Review | 4-2010 | 4-2009 |
| AD II-8 | Forensic Investigation | 4-2010 | 4-2009 |
| AD II-9 | Nursing Quality Control Monitoring | 1-2012 | 4-2011 |
| AD II-10 | Health Services Comprehensive Audits | 3-2013 | 3-2013 |
| AD II-11 | Instruments, Sharps, Key Control | 4-2010 | 3-2009 |
| AD II-12 | Identification of Patients | N/A | 9-2013 |
| AD II-13 | Cardiopulmonary Resuscitation | N/A | 12-2013 |
| AD II-14 | Electronic Event Reporting System | 10-2017 | 10-2017 |
| III. Managed Care | |||
| AD III-1 | 1-2016 | 1-2016 | |
| AD III-2 | Processing Disability Claims | 5-2010 | 5-2002 |
| AD III-3 | Utilization Review Plan | 6-2014 | 6-2014 |
| AD III-4 | Cosmetic Surgery | 11-2010 | 5-2002 |
| AD III-5 | Medical Claims Receipt | 1-2012 | 10-2007 |
| AD III-6 | Pended UR Requests | 9-2016 | 9-2016 |
| AD III-7 | Utilization Review Policies | 4-2010 | 12-2010 |
| IV. Patient's Rights | |||
| AD IV-1 | Informed Consent | 2-2014 | 2-2014 |
| AD IV-2 | Involuntary Commitment | 4-2010 | 9-2007 |
| AD IV-3 | Confidentiality | 6-2017 | 6-2017 |
| AD IV-4 | Medical Research | 5-2014 | 5-2014 |
| AD IV-5 | Inmate Right to Refuse Medical Treatment | 5-2014 | 5-2014 |
| AD IV-6 | Access to Foreign Language Translation | 1-2012 | 1-2012 |
|
V. Death and Dying |
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| AD V-1 | Rights to a Natural Death | 1-2012 | 2-2002 |
| AD V-2 | Procedures in Case of Death of an Inmate | 6-2012 | 6-2012 |
| AD V-3 | Organ Donations | 1-2010 | 1-2009 |
| AD V-4 | Transporting Bodies | 5-2010 | 5-2010 |
| AD V-5 | Revocation of DNR Orders | 4-2010 | 4-2009 |
| AD V-6 | Right to Healthcare Decisions | 5-2011 | 5-2011 |
| AD V-7 | Recognition of DNR Status | N/A | 1-2012 |
| VI. Medical Records | |||
| AD VI-1 | Purpose and Composition of Medical Record | 5-2014 | 5-2014 |
| AD VI-2 | Deleted | ||
| AD VI-3 | Release of Confidential Information | 5-2014 | 5-2014 |
| AD VI-4 | Combining Records & Creating Additional Volumes | 8-2014 | 8-2014 |
| AD VI-5 | Mental Health Records/Tracking System | 6-2010 | 1-2006 |
| AD VI-6 | Photographs and Videotapes | 5-2014 | 5-2014 |
| AD VI-7 | Transfer of Medical Records | 5-2014 | 5-2014 |
| AD VI-8 | Record Retention | 8-2010 | 8-2010 |
| AD VI-9 | Deleted | ||
| AD VI-10 | Deleted | ||
| AD VI-11 | Deleted | ||
| AD VI-12 | Basic Medical Record Documentation | 4-2014 | 4-2014 |
| AD VI-13 | Forms Management | 5-2014 | 5-2014 |
| AD VI-14 | Problem List | 9-2014 | 9-2014 |
| AD VI-15 | Dialysis Records | 9-2016 | 9-2016 |
| AD VI-16 | Recording Data in OPUS | 9-2016 | 9-2016 |
| AD VI -17 | HERO Downtime Policy and Procedure | 9-2016 | 9-2016 |
| VII. Facilities | |||
| AD VII-1 | Facilities, Equipment, Supplies | 1-2012 | 4-2011 |
| AD VII-2 | First Aid Kits | 7-2010 | 9-2005 |
| AD VII-5 | Emergency Medical Response | 6-2012 | 6-2012 |
| VIII. Reporting | |||
| AD VIII-2 | Notification of Serious Illness, Injury or Death of Hospitalized Patient | 8-2010 | 3-2004 |
| AD VIII-3 | Duty to Warn | 1-2014 | 1-2014 |
| AD VIII-4 | Deleted refer to CP 18 | Deleted | Deleted |
| AD VIII-5 | Reporting Positive Drug Finding During Dx. Work-up | 3-2014 | 3-2014 |
| AD VIII-6 | Medical Notification to Excuse from Work | 11-2014 | 11-2014 |
| P - Personnel | |||
| P-1 | Nursing Staffing Standards | 1-2012 | 1-2012 |
| P-2 | Rescinded | ||
| P-3 | Continuing Education | 5-2010 | 5-2008 |
| P-4 | Use of Physician Extenders | 8-2010 | 8-2009 |
| P-5 | Use of Inmates in Delivery of Health Care | 1-2012 | 10-2007 |
| P-6 | Nursing: Verification of Valid Professional Licenses/Listings | 1-2012 | 4-2011 |
| P-7 | Medication Technicians | 1-2016 | 1-2016 |
| P-8 | Nursing Coverage | 1-2012 | 3-2010 |
| P-9 | Nursing Orientation, Mandatory Training and Competency Evaluation | 1-2012 | 5-2010 |
| P-10 | Requesting Flexible Schedule | 1-2012 | 1-2012 |
| P-11 | Social Work Staffing | 5-2012 | 5-2012 |
| II. Employee Health | |||
| P II-1 | Moved to IC-11 | ||
| P II-2 | Moved to IC-12 | ||
| P II-3 | Moved to IC-13 | ||
| P II-4 | Moved to IC-14 | ||
| P II-5 | BBP Exposure to DOP Employees | 7-2014 | 7-2014 |
| P II-6 | Moved to IC-10 | ||
| A - Assessment of Patient | |||
| A-1 | Receiving Screening | 1-2014 | 1-2014 |
| A-2 | Intake Physical Exam and PULHEAT System | 7-2017 | 7-2017 |
| A-3 | Lab Services | 5-2014 | 5-2014 |
| A-4 | Radiology Services | 5-2014 | 5-2014 |
| A-5 | Offenders in Segregation | 11-2014 | 11-2014 |
| A-6 | Deleted March 19, 2018 | ||
| A-7 | Court Ordered STD Testing | 2-2014 | 2-2014 |
| A-8 | Paternity Testing | 11-2014 | 11-2014 |
| A-9 | Patient Acuity Rating System | 4-2016 | 4-2016 |
| A-10 | Falls Screening Alert | 4-2010 | 8-2004 |
| A-11 | Vision Screening | 3-2017 | 3-2017 |
| A-12 | 4-2018 | 4-2018 | |
| A-13 | Infusion Therapy and Blood | N/A | 1-2016 |
| PL - Planning Patient Care | |||
| PL-1 | Procedures for Chronic Disease | 6-2013 | 6-2013 |
| PL-2 | Initial Nursing Care Plan for Mental Health | 1-2012 | 3-2002 |
| PE - Patient Education | |||
| PE-1 | Health Orientation | 1-2014 | 1-2014 |
| PE-2 | Inmate Health Education/Health Promotion | 10-2014 | 10-2014 |
| PE-3 | Refer to Policy N-1 Deleted | Policy Deleted | Policy Deleted |
| PE-4 | Refer to Policy TX-7 Deleted | Policy Deleted | Policy Deleted |
| TX - Care and Treatment of Patient | |||
| I. Access to Services | |||
| TX I-1 | Sick Call | 1-2016 | 1-2016 |
| TX I-2 | Specialty Medical Clinics | 9-2016 | 9-2016 |
| TX I-3 | Mental Health Clinics | 6-2011 | 6-2011 |
| TX I-4 | Medical Treatment Services Outside DOP | 7-2012 | 7-2012 |
| TX I-5 | Mental Health Services Outside DOP | Policy Deleted | Policy Deleted |
| TX I-6 | Mental Health Day Treatment | 04-2018 | 04-2018 |
| TX I-8 | Telephone Triage | 1-2017 | 1-2017 |
| TX I-9 | Detoxification and Drug Withdrawal | 1-2012 | 1-2012 |
| TX I-10 | Oxygen | 6-2014 | 6-2014 |
| TX I-11 | Mass Casualties | 9-2016 | 9-2016 |
| TX I-12 | Mental Health Outpatient Services - Telepsychiatry Clinics | 04-2018 | 4-2018 |
| TX I-13 | Evaluation and Management of Transgender Offenders | 08-2018 | 08-2018 |
| TX I-14 | Adult Residential Treatment Services | N/A | 10-2013 |
| II. Medication Administration | |||
| TX II-1 | Drug Formulary | 2-2017 | 2-2017 |
| TX II-2 | Deleted and Combined into TX II-4 | ||
| TX II-3 | Valid Orders and Treatment Protocols | 1-2017 | 1-2017 |
| TX II-4 | Medication Procurement and Returns | 1-2017 | 1-2017 |
| TX II-5 | Starter Dose Program | 1-2017 | 1-2017 |
| TX II-6 | Inmate Transferred on Medication | 2-2017 | 2-2017 |
| TX II-7 | Methods of Medication Administration | 08-2017 | 08-2017 |
| TX II-8 | Involuntary Administration of Psychotropic Medication | 6-2012 | 6-2012 |
| TX II-9 | Medication Duration for Outpatient Services | 1-2017 | 1-2017 |
| TX II-10 | Refer to TX-7 | N/A | N/A |
| TX II-11 | Psychotropic Medication Review | 12-2016 | 12-2016 |
| TX II-12 | Controlled Substances | 1-2017 | 1-2017 |
| TX II-13 | Non-Prescription Medication in Canteen | 1-2017 | 1-2017 |
| TX II-14 | Drug Storage | 1-2017 | 1-2017 |
| TX II-15 | Drug Recall | 1-2017 | 1-2017 |
| TX II-16 | Inmate Release with Medications | 7-2017 | 7-2017 |
| TX II-17 | Deleted and Combined into TX II-1 | ||
| TX II-18 | Inmate Medication Refill Request System | 4-2012 | 4-2012 |
| TX II-19 | Deleted | ||
| TX II-20 | Transcription of Orders | 1-2012 | 6-2011 |
| TX II-21 | Deleted | ||
| TX II-22 | Mental Health Preferred Drug List | N/A | 11-2010 |
| TX II-23 | Automated Dispensing Cabinets | 1-2018 | 1-2018 |
| TX II-24 | USP-800 Hazardous Drugs-Handling in Healthcare Settings | 11/01/19 | 11/01/19 |
| III. Restrictive Procedures | |||
| TX III-1 | Therapeutic Seclusion | 7-2010 | 9-2007 |
| TX III-2 | Therapeutic Restraint | 7-2010 | 10-2008 |
| TX III-3 | Use of Restraints for Medical Purposes | 10-2014 | 10-2014 |
| TX III-4 | Use of Administrative Segregation for Behavioral Observation | 7-2010 | 10-2008 |
| TX III-5 | Assessment and Care of Patient on Special Management Meals | 10-2014 | 10-2014 |
| TX III-6 | Assessment and Care for Patient on Finger Food Diet | 10-2010 | 10-2008 |
| TX III-7 | 6-2016 | 6-2016 | |
| TX III-8 | Medical Care After Use of Force and/or Incidents Involving Trauma to an Inmate | 10-2014 | 10-2014 |
| TX III-9 | Suicide Prevention Program | 6-2016 | 6-2016 |
| IV. Infection Control | |||
| TX-VI | Moved to IC Section of Manual | Policy Moved | Policy Moved |
| V. Dental Services | |||
| TX V-1 | Dental Responsibilities | 5-2014 | 5-2014 |
| TX V-2 | Asepsis Dental Procedures | 5-2014 | 5-2014 |
| TX V-3 | Dental Exams and Assessment | 3-2016 | 3-2016 |
| TX V-4 | Access to Dental Care and Dental Priorities | 5-2014 | 5-2014 |
| TX V-5 | Preventive Dentistry | 5-2014 | 5-2014 |
| TX V-6 | Types of Dental Treatments Provided | 3-2016 | 3-2016 |
| TX V-7 | Periodontal Treatment | 3-2016 | 3-2016 |
| TX V-8 | Orthodontics | 5-2014 | 5-2014 |
| TX V-9 | Dental Records and Reports | 5-2014 | 5-2014 |
| TX V-10 | Dental Hygiene Under Direction | 5-2014 | 5-2014 |
| TX V-11 | Dental Holds | 3-2016 | 3-2016 |
| VI. Activities of Daily Living | |||
| TX VI-1 | Inmate Personal Hygiene | 1-2012 | 2-2002 |
| TX VI-2 | Therapeutic Diets & Supplemental Nourishment | 8-2010 | 8-2009 |
| TX VI-3 | Refer to Policy N-5 Deleted | Policy Deleted | Policy Deleted |
| TX VI-4 | Grinding of Toe Nails & Calluses | 11-2010 | 2-2002 |
| VII. Disabilities | |||
| TX VII-1 | Development Disabilities | 8-2010 | 8-2007 |
| TX VII-2 | Physical, Mental, or Cognitive Disabilities | 8-2010 | 8-2009 |
| TX VII-3 | Medical Prosthesis and Appliances Including Footwear | 10-2014 | 10-2014 |
| CC - Continuity Patient Care | |||
| CC-1 | Continuity of Care | 4-2014 | 4-2014 |
| CC-2 | Hospitalization & In-Patient Medical Services | 4-2014 | 4-2014 |
| CC-3 | Transfers, Appropriate Medical Placements & Medical Holds | 5-2014 | 5-2014 |
| CC-4 | Pregnant Inmates | 3-2014 | 3-2014 |
| CC-5 | Aged and Infirmed Inmate | 5-2014 | 5-2014 |
| CC-6 | Mental Health Services - Case Finding and Patient Flow | 5-2018 | 5-2018 |
| CC-7 | Transfer Procedures for Referral to Mental Health | 8-2010 | 10-2008 |
| CC-8 | Aftercare Planning for Inmate Health Services | 1-2012 | 11-2007 |
| CC-9 | Social History | 5-2010 | 5-2003 |
| CC-11 | Extending the Limits of Confinement | 8-2017 | 8-2017 |
| CC-12 | Medical Release8 | 8-2017 | 8-2017 |
| CC-13 | Inmate and Family Correspondence and Calls | 3-2014 | 3-2014 |
| CC-14 | Medicaid Application Process | N/A | 12-2012 |
| N - Nutrition | |||
| N-1 | Therapeutic Diet Orientation | 03-2016 | 03-2016 |
| N-5 | Management of Offenders Refusing to Eat | 10-2014 | 10-2014 |
| IC - Infection Control | |||
| IC-1 | Sterilization & Disinfection | 1-2016 | 1-2016 |
| IC-2 | Sanitation of Medical Areas & Equipment | 9-2016 | 9-2016 |
| IC-3 | Communicable Disease | 1-2016 | 2-2016 |
| IC-4 | Standard Precautions | 1-2015 | 1-2015 |
| IC-5 | Inmate Exposure to BBP | 9-2016 | 9-2016 |
| IC-6 | Tuberculosis Control Plan | 9-2016 | 9-2016 |
| IC-7 | Management of HIV Infection/Acquired | 1-2012 | 9-2010 |
| IC-8 | Immunizations | 5-2016 | 5-2016 |
| IC-10 | BBP Exposure/Employees of Other Agencies | 9-2016 | 9-2016 |
| IC-11 | Employee Vaccinations and TB Screening | 9-2016 | 9-2016 |
| IC-12 | Injuries to Staff and Occupational Exposure to DPS Staff and Staff from other Agencies | 1-2016 | 1-2016 |
| IC-13 | Treatment of Injured or Sick Staff | 9-2016 | 9-2016 |
| IC-14 | Health Care Worker's Infected with HIV and/or HBV | 1-2016 | 1-2016 |