Dialysis Policy and Procedure Manual
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- Changes
- Table of Contents - TJC standards and CMS Regulations
- Copyright
- Disclaimer
- Approval/Signature Sheet
- Introduction
- SECTION 01 - EMERGENCY MANAGEMENT
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SECTION 02 - ENVIRONMENT OF CARE
- 2001 - Safety Management Plan
- 2002 - Dialysis Safety
- 2003 - Patient Care Environment
- 2004 - Sinks for Handwashing
- 2005 - Security - Dialysis Services
- 2006 - Electrical Safety
- 2007 - Life Safety Code Compliance
- 2008 - Fire Safety
- 2009 - Fire Safety - Smoking Policy
- 2010 - Types of Fire Extinguishers
- 2011 - Use of a Fire Extinguisher
- 2012 - Hazardous Materials and Waste - Nursing Services
- 2013 - Hazardous Materials and Waste - Training
- 2014 - Chemical Training Record Form
- 2015 - How to Read Safety Data Sheets (SDS)
- 2016 - Equipment Maintenance
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SECTION 03 - HUMAN RESOURCES
- 3001 - Position Description/Performance Evaluation - Dialysis Services Medical Director
- 3002 - Performance Evaluation - Population-Specific/Age-Related Competency - Dialysis Services Medical Director
- 3003 - Annual Competency Clinical Skills Assessment - Dialysis Services Medical Director
- 3004 - Position Description/Performance Evaluation - Dialysis Services Nurse Manager
- 3005 - Performance Evaluation - Population-Specific/Age-Related Competency - Dialysis Services Nurse Manager
- 3006 - Annual Competency Clinical Skills Assessment - Dialysis Services Nurse Manager
- 3007 - Position Description/Performance Evaluation - Dialysis Services Charge Nurse
- 3008 - Performance Evaluation - Population-Specific/Age-Related Competency - Dialysis Services Charge Nurse
- 3009 - Annual Competency Clinical Skills Assessment - Dialysis Services Charge Nurse
- 3010 - Position Description/Performance Evaluation - Dialysis Services Staff RN
- 3011 - Performance Evaluation - Population-Specific/Age-Related Competency - Dialysis Services Staff RN
- 3012 - Annual Competency Clinical Skills Assessment - Dialysis Services Staff RN
- 3013 - Position Description/Performance Evaluation - Dialysis Services Registered Dietitian
- 3014 - Performance Evaluation - Population-Specific/Age-Related Competency - Dialysis Services Registered Dietitian
- 3015 - Annual Competency Clinical Skills Assessment - Dialysis Services Registered Dietitian
- 3016 - Position Description/Performance Evaluation - Dialysis Services Licensed Clinical Social Worker
- 3017 - Performance Evaluation - Population-Specific/Age-Related Competency - Dialysis Services Licensed Clinical Social Worker
- 3018 - Annual Competency Clinical Skills Assessment - Dialysis Services Licensed Clinical Social Worker
- 3019 - Position Description/Performance Evaluation - Dialysis Services Patient Care Technician
- 3020 - Performance Evaluation - Population-Specific/Age-Related Competency - Dialysis Services Patient Care Technician
- 3021 - Annual Competency Clinical Skills Assessment - Dialysis Services Patient Care Technician
- 3022 - Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol
- 3023 - BCLS Resuscitation Certification
- 3024 - Restraint and Seclusion - Staff Training and Competency
- 3025 - Restraint Use Competency Checklist - Restraint for Management of Nonviolent, Non-Self Destructive Behavior
- 3026 - Staff Qualifications and Competency
- 3027 - Overview of Dialysis Services Facility Staff Qualifications
- 3028 - Dialysis Services Patient Care Technician Requirements
- 3029 - New Employee Orientation
- 3030 - Dialysis Services Orientation Checklist
- 3031 - Skills Orientation Checklist - Dialysis Services
- 3032 - Contract Services Staff Checklist - Dialysis Services
- 3033 - Staff Education and Training
- 3034 - Education Profiles
- 3035 - Performance Evaluations
- 3036 - Dress Code
- 3037 - Employee Health Record
- 3038 - On-the-Job (Workers' Compensation) Injured Employee Processing
- 3039 - Return to Work After Illness/Injury Policy
- 3040 - Physician's Certification of Illness - Sample Form
- 3041 - Attendance and Tardiness
- 3042 - Disciplinary Action
- 3043 - Employee Photo Identification Badge
- 3044 - Employee Requests for Time Off
- 3045 - Harassment, Sexual (Either Sex)
- 3046 - Holiday Policy
- 3047 - Meal Periods and Rest Breaks
- 3048 - Personal Telephone Calls To/From Employees
- 3049 - Sick Leave Policy
- 3050 - Vacation Policy
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SECTION 04 - INFECTION PREVENTION AND CONTROL
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General Policies
- 4001 - Infection Prevention and Control Program
- 4002 - Infection Prevention and Control - Staff Education
- 4003 - Reporting of Clusters of Adverse Events (Infectious or Non?Infectious)
- 4004 - Standard Precautions
- 4005 - Transmission-Based Precautions (Isolation Precautions)
- 4006 - Hand Hygiene - CDC Guidelines
- 4007 - Infection Prevention and Control Practices
- 4008 - Cleaning and Disinfection of Medical Devices and Equipment
- 4009 - Multiple Dose Vials (MDVs) - Use of
- 4010 - Single-Use/Single-Dose Vials - Use
- 4010A - Saline Syringes - Preparation of
- 4011 - Personal Protective Equipment (PPE)
- 4012 - Gloves
- 4013 - Hepatitis B Vaccine Program
- 4014 - Routine Serologic Testing for Chronic Hemodialysis Patients
- 4015 - Postvaccination Testing and Revaccination of Nonresponders - Hepatitis B
- 4016 - Informed Consent for Hepatitis B Vaccine Form
- 4017 - Hepatitis B Vaccine Declination Form
- 4018 - Care of HBV-Positive Patients in Isolation
- 4019 - Isolation Rooms for HBV-Positive Patients
- 4020 - TB - Exposure Control Plan
- 4021 - Baseline and Follow-up Testing for M. Tuberculosis Infection
- 4022 - Prevention Strategies for Seasonal Influenza in Healthcare Settings
- 4023 - Disposal of Sharps
- 4024 - Sharps Injury Protection Plan
- 4025 - Sharps Injury Log Form
- 4026 - Handling of Biohazardous Waste
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Water and Dialysate/Dialysis Fluid Quality
- 4101 - Water and Dialysate/Dialysis Fluid - General Issues
- 4102 - Water Purity
- 4103 - Bacteriology of Water (Dialysis Water Requirements)
- 4104 - Bacteriology of Conventional Dialysate (Standard Dialysis Fluid)
- 4105 - Bacteriology of Ultrapure Dialysate/Dialysis Fluid
- 4106 - Quality Management - Communication with Feed-Water Supplier
- 4107 - Dialysis Fluid Handling System - Technical Aspects
- 4108 - Back-Up Plan in the Event of Water and/or Electrical Failure
- 4109 - Water Treatment and Dialysate/Dialysis Fluid Preparation Systems - Record Retention
- 4110 - Water Purification and Storage System
- 4111 - Sediment Filters
- 4112 - Cartridge Filters
- 4113 - Water Softener
- 4114 - Carbon Adsorption - Systems to Protect Patients from Chlorine and Chloramine
- 4115 - Carbon Adsorption Monitoring and Testing
- 4116 - Chemical Injections - Systems to Protect Patients from Chlorine and Chloramine
- 4117 - Reverse Osmosis (RO)
- 4118 - Deionization
- 4119 - Ultrafiltration (Endotoxin-Retentive Filter)
- 4120 - Water Storage and Distribution System
- 4121 - Ultraviolet Irradiators (UV Lights)
- 4122 - Ozone Generators
- 4123 - Hot Water Disinfection Systems
- 4124 - Disinfection of Distribution Piping and the Supply Line
- 4125 - Mixing Systems
- 4126 - Acid Concentrate Mixing Systems
- 4127 - Bicarbonate Concentrate Mixing Systems
- 4128 - Additives - Mixing Spikes
- 4129 - Bicarbonate Concentrate Distribution Systems
- 4130 - Labeling of Concentrate Delivery Piping
- 4131 - Monitoring Dialysate/Dialysis Fluid pH/Conductivity
- 4132 - Quality Control/Quality Assurance of Dialysate/Dialysis Fluid Quality
- 4133 - Microbial Monitoring - Monthly Dialysis Water Samples
- 4134 - Microbial Monitoring - Dialysate/Dialysis Fluid
- 4135 - Staff Training for Water and Dialysate Systems
- 4136 - Adverse Events - Patient Reactions
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General Policies
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SECTION 05 - LEADERSHIP
- 5001 - Scope of Services - Dialysis Services
- 5002 - Governing Body
- 5003 - Culture of Safety and Quality - Dialysis Services
- 5004 - Furnishing Services
- 5005 - ESRD Network
- 5006 - Furnishing Information to CMS
- 5007 - Disclosure of Ownership
- 5008 - Medical Staff Appointments
- 5009 - Dialysis Services Medical Director - Qualifications and Responsibilities
- 5010 - Nursing Services
- 5011 - Staffing - Dialysis Services
- 5012 - Emergency Coverage
- 5013 - On-Call - Dialysis Services
- 5014 - Laboratory Services
- 5015 - Sentinel Event
- 5016 - Patient Safety Plan
- 5017 - Staff Rights and Ethical Dilemmas in Patient Care
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SECTION 06 - MEDICATION MANAGEMENT
- 6001 - Medication Administration
- 6002 - Pediatric Dosing - General Guidelines
- 6003 - Medication and Solution Administration - Invasive Procedures
- 6004 - Verbal and Written Orders - General
- 6005 - Telephone, Verbal and Written Orders for Medication
- 6006 - Emergency Crash Carts
- 6007 - Emergency Crash Cart Security and Accountability
- 6008 - Emergency Medications
- 6009 - Contents of Emergency Adult Crash Cart Form (Example)
- 6010 - Administration of Emergency Medications Through Dialysis Catheter
- 6011 - Heparin - Independent Double Check
- 6012 - Safe Medication Practices
- 6013 - Decreasing Medication Errors
- 6014 - Medication Errors
- 6015 - Medication Incident Report Policy
- 6016 - Medication Incident Report Form
- 6017 - Medication Error Analysis Report
- 6018 - Performance Improvement Analysis - Medication Incident Form
- 6019 - Adverse Drug Reaction Reporting
- 6020 - Adverse Drug Reaction Reporting Form (Internal)
- 6021 - Potential Adverse Drug Reaction Form
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SECTION 07 - PERFORMANCE IMPROVEMENT
- 7001 - Performance Improvement Plan
- 7002 - Dialysis Services PI Monitoring and Evaluation Plan
- 7003 - Dialysis Services PI Trending Sheet
- 7004 - Dialysis Services PI Outcome Evaluation
- 7005 - Incident Reporting
- 7006 - Performance Improvement Indications and Notification Form - Dialysis Services
- 7007 - Performance Improvement Quarterly Report Form
- 7008 - Patient Satisfaction Tool - ICH CAHPS Survey
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SECTION 08 - PROVISION OF CARE, TREATMENT AND SERVICES
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Admission, Assessment and Reassessment
- 8001 - Admission Policy
- 8002 - Initial Assessment
- 8003 - Nursing Assessment
- 8004 - Interdisciplinary Team
- 8005 - Comprehensive Assessment
- 8006 - Assessment of the Hemodialysis (HD) Treatment Prescription
- 8007 - Assessment of the Peritoneal Dialysis (PD) Treatment Prescription
- 8008 - Drawing Blood Samples to Measure Kt/v
- 8009 - Blood Pressure and Fluid Management Needs
- 8010 - Laboratory Profile
- 8011 - Immunization History
- 8012 - Medication Patient Information and Reconciliation
- 8013 - Medication Patient Information and Reconciliation Form
- 8014 - Anemia Management
- 8015 - Erythropoiesis-Stimulating Agents (ESAs)
- 8016 - Mineral Metabolism - Evaluation of Factors Associated with Renal Bone Disease
- 8017 - Nutritional Assessment
- 8018 - Nutritional Plan of Care
- 8019 - Psychosocial Assessment and Plan of Care
- 8020 - Community Resources List
- 8021 - Assessment and Maintenance of Dialysis Access
- 8022 - Patient Preferences for Modality and Self-Care
- 8023 - Evaluation for Transplant Referral
- 8024 - Evaluation of Family/Support Systems
- 8025 - Evaluation for Referral to Rehabilitation Services
- 8026 - Fall Prevention
- 8027 - Assessment of Adult Patient/Resident at Risk for Falls Form
- 8028 - Latex Sensitive Patient - Care of
- 8029 - Latex Allergy Assessment Form
- 8030 - Pain Assessment, Reassessment and Management
- 8031 - Pain Scale
- 8032 - Pain Scale Examples
- 8033 - Reassessment
- 8034 - Patient Plan of Care
- 8035 - Patients Seen by a Practitioner During Dialysis Treatments
- 8036 - Transplantation Referral Tracking
- 8037 - Dialysis Nursing Responsibilities
- 8038 - Checking of Safety Features Prior to Dialysis Treatment
- 8039 - Pre-Treatment Checklist
- 8040 - Dialysis Machine Preassessment
- 8041 - Dialyzer Preparation
- 8042 - Pre-Dialysis Nursing Assessment
- 8043 - Assessing Patency of Arteriovenous Fistula/Graft
- 8044 - Intradialytic Assessment and Monitoring
- 8045 - Care of Patient Post-Hemodialysis
- 8046 - Patient Condition Report
- 8047 - Calculating Fluid Replacement
- 8048 - Measurement of Recirculation in the Vascular Access
- 8049 - Patient Identification for Clinical Care and Treatment
- 8050 - "Hand Off" Communication
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Patient Care Procedures
- 8101 - AV Fistula or Vein Graft - Initiating Dialysis for Mature Access
- 8102 - Initiation of Hemodialysis Using Dual Lumen Catheter
- 8103 - Dual Lumen Catheter Dressing Change
- 8104 - Discontinuing Hemodialysis with a Dual Lumen Catheter
- 8105 - Access Complications/Aneurysms
- 8106 - Air Embolus
- 8107 - Allergic Reactions During Dialysis
- 8108 - Angina Pectoris During Dialysis
- 8109 - Arrhythmias During Dialysis
- 8110 - Blood/Blood Components - Transfusion
- 8111 - Blood/Blood Components - Transfusion Reactions
- 8112 - Blood Cultures
- 8113 - Blood Leak
- 8114 - Blood Loss from Extracorporeal System
- 8115 - Central Venous Lines and PICC Lines - Insertion of
- 8116 - Critical Results of Tests and Diagnostic Procedures - Reporting of
- 8117 - Code Blue During Dialysis
- 8118 - Defibrillators
- 8119 - Emergency Equipment
- 8120 - Disequilibrium Syndrome
- 8121 - Dyspnea During Dialysis
- 8122 - Formaldehyde Reaction
- 8123 - Frequent Patient Complaints/Complications
- 8124 - Hemolysis
- 8125 - Hyperkalemia
- 8126 - Hypoglycemia
- 8127 - Hypertension During Acute Dialysis
- 8128 - Hypotension - Shock During Dialysis
- 8129 - Intravascular Catheter-Related Infections - Prevention of
- 8130 - Labeling of Specimens
- 8131 - Multidrug-Resistant Organisms in Acute Care Settings - Management of
- 8132 - Observation of the Patient During Treatment
- 8133 - Obtaining Blood Samples
- 8134 - Post Dialysis Hypotension
- 8135 - Muscle Cramping During Dialysis
- 8136 - Peritoneal Dialysis - Assessment of Patient During Treatment
- 8137 - Peritoneal Dialysis (Straight Set or Y-Set)
- 8138 - Peritoneal Dialysis - Exit Site Care
- 8139 - Continuous Ambulatory Peritoneal Dialysis (CAPD) Exchange Procedure
- 8140 - Pyrogen Reaction
- 8141 - Restraint or Seclusion Use
- Patient and Family Education
- Involuntary Discharge Procedure
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Care at Home
- 8401 - Introduction - Care at Home
- 8402 - Home Dialysis Program
- 8402A - Provision of Dialysis Services in Long Term Care
- 8403 - Training for Home Dialysis Patients
- 8404 - Home Dialysis Monitoring
- 8405 - Support Services
- 8406 - Bacteriological and Endotoxin Testing
- 8407 - Notifying Utility Companies
- 8408 - Home Hemodialysis Issues
- 8409 - Home Dialysis Supplies and Equipment
- 8410 - Emergency Back-Up Dialysis Services
- 8411 - Record Keeping
- 8412 - On-Call Staff for Home Dialysis Patients
- 8413 - HBV-Positive Home Dialysis Patient
- Resource
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Admission, Assessment and Reassessment
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SECTION 09 - RECORD OF CARE, TREATMENT AND SERVICES/INFORMATION MANAGEMENT
- 9001 - Information Management Plan
- 9002 - Medical Record Content
- 9003 - Documentation
- 9004 - Hemodialysis Flowsheet (Example)
- 9005 - Peritoneal Dialysis Flowsheet (Example)
- 9006 - Legibility of Medical Record Documentation
- 9007 - Documentation and the Use of Abbreviations, Acronyms and Symbols
- 9008 - Unacceptable Abbreviation and Symbol List
- 9009 - Health Data Integrity
- 9010 - Uses and Disclosures of Protected Health Information - General Rules
- 9011 - Release of Medical Information
- 9012 - Medical Record Retention
- 9013 - Transfer of Patient Record Information
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SECTION 10 - RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL
- 10001 - Dialysis Services Facility Patient Rights and Responsibilities
- 10002 - Patient Rights and Responsibilities
- 10003 - Informing Patients About the Dialyzer Reprocessing Program
- 10004 - Advanced Beneficiary Notice (ABN)
- 10005 - Confidentiality of Information - General Issues
- 10006 - Informed Consent
- 10007 - Dialysis Informed Consent Policy
- 10008 - Blood/Blood Component - Informed Consent
- 10009 - Blood/Blood Component Transfusion Consent Form
- 10010 - Advance Directives
- 10011 - Child, Adult, Disabled Person or Elderly Abuse - Recognition and Reporting
- 10012 - Patient Complaint and Grievance Process
- SECTION 11 - WAIVED TESTING