Table of Contents: Institutional Handbook of Operating Procedures

The policies in this section have been vetted through the review and approval process in accordance with The University of Texas Medical Branch at Galveston’s Institutional Handbook of Operating Procedures (IHOP), established under the guidelines of The University of Texas System, Board of Regent’s Rules.
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SECTION 1     IHOP  -  Official Governance
IHOP - 01.01.01 Institutional Mission Statement of the University of Texas Medical Branch (UTMB)
IHOP - 01.01.02 Rules and Regulations of the Board of Regents
IHOP - 01.01.03 Institutional Handbook of Operating Procedures
IHOP - 01.01.04 Intellectual Property
SECTION 2     IHOP  -  General Administration
IHOP - 02.01.03 - Release of Information Under the Texas Public Information Act
IHOP - 02.01.05 - Business Continuity Planning
IHOP - 02.06.01 - Use of UTMB Facilities
IHOP - 02.06.02 - Special Use Facilities
IHOP - 02.06.03 - Naming of Buildings, Other Facilities, and Entities
IHOP - 02.06.04 - Registering a Faculty, Staff or Student Organization
IHOP - 02.06.06 - Posting of Notices on Institutional Bulletin Board
IHOP - 02.06.07 - Fundraising Projects Benefiting UTMB
IHOP - 02.06.09 - Food Services Policy
IHOP - 02.06.10 - Food Services Contracting Policy
IHOP - 02.07.01 - Signage and Wayfinding Approval
IHOP - 02.07.02 - Space Management
IHOP - 02.19.03 - Mobile Communication Devices
IHOP - 02.19.04 - UTMB Web Accessibility Policy
IHOP - 02.19.06 - Information Resources Security
IHOP - 02.19.07 - Use of Social Media
IHOP - 02.19.09 - Digital Millennium Copyright Act Notice and Procedures
SECTION 3.1     IHOP  -  Employee  -  General
IHOP - 03.01.01 - Staffing During Adverse Conditions
IHOP - 03.01.02 - Employee Files
IHOP - 03.01.04 - Performance Management Program
IHOP - 03.01.06 - Personal Appearance
IHOP - 03.01.09 - Discipline, Dismissal and Appeal for Classified Employees
IHOP - 03.01.10 - Grievance Policy
IHOP - 03.05.04 - Telecommuting (Alternate Work Site)
IHOP - 03.07.01. - Attendance
IHOP - 03.07.10 - Work Schedules and Work Week
SECTION 3.2     IHOP  -  Employee  -  Regulatory Compliance
IHOP - 03.02.01 - Nondiscrimination, Equal Employment Opportunity and Affirmative Action
IHOP - 03.02.02 - Americans with Disabilities Act Policy
IHOP - 03.02.04 - Sexual Harassment and Misconduct
IHOP - 03.02.06 - Criminal Background Checks for Employment
IHOP - 03.02.09 - Non-Retaliation Policy
IHOP - 03.03.01 - Verification of Selective Service Registration
IHOP - 03.03.04 - Eligibility and Tax Requirements
IHOP - 03.03.06 - Verification of Debarred and Suspended Individuals and Organizations
SECTION 3.3     IHOP  -  Employee  -  Employment
IHOP - 03.03.02 - Faculty and Administrative & Professional Recruitment
IHOP - 03.03.03 - Processing Non-Citizen Employees and Students
IHOP - 03.03.06 - Employment of Relatives (Nepotism)
IHOP - 03.03.07 - New Employee Probationary Period
IHOP - 03.03.09 - Classified Staff Recruitment and Transfer
IHOP - 03.03.11 Eligibility for Re-employment Process
IHOP - 03.03.16 - Dual State Employment
IHOP - 03.07.12 - Employee Exit Process
IHOP - 03.07.13 - Reduction in Force (RIF)
SECTION 3.4     IHOP  -  Employee  -  Compensation
IHOP 03.04.01 Compensation Policy for Professional and Classified Employees
IHOP 03.04.09 - Pay for On-Call Classified Employees
IHOP - 03.04.02 Fair Labor Standards Act Regarding Deductions from Salary of UTMB Exempt Employees
IHOP - 03.04.03 - Compensatory Time
IHOP - 03.04.10 - Overtime
IHOP - 03.04.11 - Shift Differential
IHOP - 03.04.13 - Longevity Pay
SECTION 3.5     IHOP  -  Employee  -  Training and Development
IHOP - 03.05.02 - Tuition Reimbursement for College Credit Coursework
IHOP - 03.05.03 - Long-Term Training (LTT)
IHOP - 03.05.04 - Mandatory Education and Training for UTMB 's Workforce
IHOP - 03.06.04 - New Employee Orientation
SECTION 3.6     IHOP  -  Employee  -  Leave
IHOP - 03.05.01 - Sick Leave Pool
IHOP - 03.06.02 - Time Off for Voting
IHOP - 03.06.09 - Family and Medical Leave
IHOP - 03.06.10 - Sick Leave
IHOP - 03.06.12 - Vacation
IHOP - 03.06.15 - Leave for Employees Donating an Organ, Bone Marrow, or Blood
IHOP - 03.07.03 - Jury Service and Witness Fees and Service
IHOP - 03.09.02 - Paid Military Leave
IHOP - 03.09.03 - Emergency Leave (Including Funeral Leave)
IHOP - 03.09.04 - Official Holidays
IHOP - 03.09.06 - Leave Without Pay
IHOP - 03.09.08 - Parental Leave
IHOP - 03.09.11 - Assistance Dog Training Leave for Employees with a Disability
IHOP - 03.09.12 - Leave for Employees Certified as Firefighter, Emergency Medical Service, and Disaster Service Volunteers
IHOP - 03.09.14 - Extended Unpaid Military Leave
SECTION 3.7     IHOP  -  Employee  -  Health and Wellness
IHOP - 03.03.17 - Fitness for Duty
IHOP - 03.03.18 - Pre-Employment Drug Testing
IHOP - 03.07.03 - Employee Assistance Program
IHOP - 03.07.04 - Temporary Job Modification
IHOP - 03.07.06 - Tobacco Free Policy
IHOP - 03.07.07 - Vaccination of Healthcare Workers to Protect Patients from Vaccine Preventable Infections
IHOP - 03.11.01 - Workers Compensation Insurance
IHOP 03.07.08 - Worksite Breast feeding
SECTION 4     IHOP  -  Fiscal
IHOP - 04.01.04 - Time and Attendance Reporting
IHOP - 04.02.01 - Historically Underutilized Businesses (HUB)
IHOP - 04.03.01 - Travel Policy
IHOP - 04.04.02 - Official Function Expenditures
IHOP - 04.04.05 - Departmental Ledger Sheets
IHOP - 04.04.13 - Cash Handling and Reporting
IHOP - 04.04.17 Membership Organization Dues
IHOP - 04.04.20 - Use of State Sales Tax Exemption Form
IHOP - 04.05.01 - Service Centers
IHOP - 04.05.02 - Consistent Treatment of Costs
IHOP - 04.05.03 - Fringe Benefit Costs
IHOP - 04.05.05.- Hiring Independent Contractors
IHOP - 04.05.06 - Procurement Policy
IHOP - 04.05.07 Cost Sharing Policy
IHOP - 04.05.08-Effort Reporting Policy
IHOP - 04.05.09-Cost Transfer Policy
IHOP - 04.07.04 Annual Inventory
SECTION 5     IHOP  -  Faculty
IHOP - 05.01.01 - Rights and Responsibilities of Faculty Members
IHOP - 05.01.02. - Faculty Governing Authority
IHOP - 05.01.04 New Faculty Teaching Physician Education
IHOP - 05.03.01 - System Policy on Faculty and Designated Appointments
IHOP - 05.03.02 - General Policies for Academic Titles
IHOP - 05.03.03 - Named Professorships and Endowed Chairs
IHOP - 05.03.04 - Retirement and Modified Service
IHOP - 05.03.05 - Faculty Recruitment Policy
IHOP - 05.03.06 - Procedures for Appointment, Promotion, or Membership in all Schools
IHOP - 05.03.07 - Joint Appointments
IHOP - 05.03.08 - Faculty Grievance Policy
IHOP - 05.03.09 - Tenure and Reappointments
IHOP - 05.03.10 - Termination
IHOP - 05.03.12 - Faculty Development Leave
IHOP - 05.03.14 Faculty Ombudsperson Policy
IHOP - 05.05.01 Faculty Evaluations
IHOP - 05.05.02 - Periodic Performance Evaluation of Tenured Faculty
IHOP - 05.05.05 - Administrative Component of Compensation for Academic Administrators
IHOP - 05.05.06 Faculty Credentials
IHOP - 05.05.07 Faculty Compensation Committee
IHOP - 05.07.05 Policy on Integrity in Research
SECTION 6.0     IHOP  -  Compliance  -  Plans
IHOP 06.01.00 Institutional Compliance Plan
IHOP 06.02.40 Privacy Compliance Plan
IHOP 06.03.01 Billing Compliance Monitoring
IHOP 06.05.00 Research Compliance Plan
IHOP 06.05.07 Export Control Compliance
IHOP 06.06.00 Endowment Compliance Plan
SECTION 6.1     IHOP  -  Compliance  -  General
IHOP - 06.01.12 Government and Outside Investigations Policy
IHOP - 06.01.03 Appeal of a Determination by the Institutional Compliance Office
IHOP - 06.01.04 Significant Events Reporting
IHOP - 06.01.05 Records and Information Management and Retention
IHOP - 06.01.10 Self Reporting Overpayments policy
SECTION 6.2     IHOP  -  Compliance  -  Privacy
IHOP - 06 02 10 - Physical Protections-Safeguards for PHI
IHOP - 06.02.00 - Maintaining Patient Confidentiality through the Appropriate Use and Disclosure of PHII
IHOP - 06.02.01 - Use and Disclosure of PHI Based on Patient Authorization
IHOP - 06.02.02 - Use and Disclosure of PHI– for Individual Care, Notification and Directory Information
IHOP - 06.02.03 - Use and Disclosure of PHI by and for Personal Representatives of Minors, Incapacitated and Deceased Individuals
IHOP - 06.02.05 - Mitigation after Improper Protected Health Information (PHI) Use or Disclosure
IHOP - 06.02.08 - Use and Disclosure of Psychotherapy Notes
IHOP - 06.02.09 - Fax Transmittal of PHI
IHOP - 06.02.13 - Use and Disclosure of PHI for Limited Data Sets
IHOP - 06.02.15 - Use of Notice of Privacy Practices of PHI
IHOP - 06.02.16 - Permitted Uses and Disclosures in Special Situations
IHOP - 06.02.17 - Use & Disclosure of PHI for Marketing and Fundraising
IHOP - 06.02.24 - Removal of Protected Health Information from UTMB Facilities
IHOP - 06.02.26 - Patient Rights Related to Amend Protected Health Information
IHOP - 06.02.29 - De-Identification of PHI
IHOP - 06.02.30 - Use & Disclosure of PHI for Research
IHOP - 06.02.32 - Verifying Identity and Authority of Individuals Requesting PHI
IHOP - 06.02.33 Research Documentation and Release of Information upon Request by Research Subjects
IHOP - 06.02.34 Use and Disclosure of Social Security Numbers (SSNs)
IHOP - 06.02.35 - Business Associates with Access to PHI
IHOP - 06.02.38 Access to Protected Health Information by External Entities (2)
IHOP - 06.02.39 Privacy Incident Response and Breach Notification
SECTION 6.3     IHOP  -  Compliance  -  Coding and Billing
IHOP 06.03.00 Clinical Billing, Documentation and Coding
IHOP 06.03.02 Correction of Errors Related to Federal Healthcare Program Reimbursement
SECTION 6.5     IHOP  -  Compliance  -  Conflicts of Interest and Ethics
IHOP - 06.05.01 - Research Conflicts of Interest
IHOP - 06.05.02 - Ethical Interactions with Industry
IHOP - 06.05.03 - Individual Conflicts of Interest Conflicts of Commitment and Outside Activities
IHOP - 06.05.04 - Institutional Conflicts of Interest
IHOP - 06.05.05 - Gifts Honoraria Fundraising and Other Activities
IHOP - 06.05.06 - Code of Ethics
SECTION 7     IHOP  -  Student
IHOP - 07.01.00 - Student Health Governance Board
IHOP - 07.01.01 - Students with Disabilities
IHOP - 07.01.03 - Student Conduct and Discipline
IHOP - 07.01.04 - Student Travel Policy
IHOP - 07.01.08 - Student Release During Adverse Conditions
IHOP - 07.01.10 - Student Accident & Injury Reporting
IHOP - 07.01.12 - Sexual Assault Policy
IHOP - 07.01.13 - Other Non-Academic Concerns
IHOP - 07.01.14 - Student Non-Academic Grievance Procedures
IHOP - 07.01.15 - GSBS - Course Content and Methodology
IHOP - 07.01.16 - GSBS - Grading and Evaluation
IHOP - 07.01.17 - GSBS - Academic Dismissal Appeals
IHOP - 07.01.18 - SOM - Appeal of Examination Score, Evaluation, or Course Grade
IHOP - 07.01.19 - SOM - Appeal of Grading and Promotion Committee Decisions
IHOP - 07.01.20 - SHP- Grading and Evaluation
IHOP - 07.01.22 - SON - Academic Appeal Grading and Evaluation
IHOP - 07.01.23 - SON - Academic Dismissal Appeal Procedures
IHOP - 07.01.24 - Tax-Free Sales By Registered Student Organizations
IHOP - 07.01.25 Student Immunization Requirements
IHOP - 07.01.27 SON Drug Testing
IHOP - 07.01.28 SOM Drug Testing Policy
IHOP - 07.01.29 Student Health Insurance
IHOP - 07.01.30 Family Educational Rights and Privacy Act (FERPA)
SECTION 8     IHOP  -  Health, Safety and Security
IHOP - 08 02 08 - Active Shooter Response Primary Document
IHOP - 08.01.01 - Policy and Guidelines on AIDS, HIV, and Hepatitis B
IHOP - 08.01.02 - Tuberculosis Surveillance Program for Healthcare Workers
IHOP - 08.01.04 - Workplace Violence
IHOP - 08.01.05 - Fire Alarm and Incident Response Policy
IHOP - 08.01.06 - Removal or Disposal of Hazardous Waste
IHOP - 08.01.07 - Evaluation and Treatment of Impaired Physicians
IHOP - 08.01.09 - Manufacture, Sale, Possession, Distribution, or Use of Alcohol, Controlled Substances or Illegal Drugs
IHOP - 08.01.11 - Environmental Policy Statement
IHOP - 08.01.12 - Safety Training
IHOP - 08.01.13 - Reproductive or Fertility Hazards in the Work Place
IHOP - 08.01.14 Decorations Safety Policy
IHOP - 08.01.15 - General Requirements for Use of Vehicles
IHOP - 08.01.16 Drug and Alcohol Testing for DOT Regulated Employees
IHOP - 08.01.19 Portable Heating Devices
IHOP - 08.01.20 Open Flames Prohibited
IHOP - 08.01.22 Public Access to Automated External Defibrillators
IHOP - 08.01.23 Above Ceiling Work Process for Healthcare Facilities
IHOP - 08.01.24 General Electrical Safety
IHOP - 08.01.25 Installation and Maintenance of Alcohol-based Hand Sanitizer Units
IHOP - 08.01.26 Keying Operations and Access
IHOP - 08.02.01 - Threatening Situations
IHOP - 08.02.02 - Campus Security Reporting
IHOP - 08.02.03 - Identification Badges or Smart Cards
IHOP - 08.02.04 - Possession of Weapons
IHOP - 08.02.05 - Security Management
IHOP - 08.02.06 - Hostage Policy Involving Offender or Correctional Patients
IHOP - 08.02.07 - Security Associated with Offender-Correctional Patients
IHOP - 08.03.01 Resource Conservation Policy
IHOP 8.2.8 Active Shooter
SECTION 9.1     IHOP  -  Clinical  -  Admission, Discharge and Transfer
IHOP - 09.01.02 - Management of Patient Belongings
IHOP - 09.01.04 - Patient Transportation
IHOP - 09.01.08 - Passes for Inpatients
IHOP - 09.01.09 - Delayed Discharge of Newborns
IHOP - 09.01.12 - Interfacility Transfer of Patients from UTMB
IHOP - 09.01.14 - Patient Discharge Planning
IHOP - 09.01.15 - Adoption from the Nurseries
IHOP - 09.01.16 - Admission of Interfacility Transfer Patients
IHOP - 09.01.21 - Examination and Treatment for Emergency Medical Conditions and Women in Labor
IHOP - 09.01.22 Determining Hospital and Emergency Department Diversion Status
IHOP - 09.01.23 MICU CCU Admission Criteria
IHOP - 09.01.24 DSU-Admission and Discharge Criteria
IHOP - 09.01.26 SICU - Admission Discharge Transfer Criteria (3)
IHOP - 09.01.27 Admission Discharge Criteria for the Chronic Home Dialysis Unit
SECTION 9.2     IHOP  -  Clinical  -  Patient Records
IHOP - 09.02.01 - Obligations of the Management of UTMB's Protected Health Information (PHI)
IHOP - 09.02.03 - Retiring Incomplete Records
IHOP - 09.02.06 - Medical Record Access
IHOP - 09.02.07 Use and Disclosure of Inpatients' Protected Health Information
IHOP - 09.02.08 - Medical Record Forms Management
IHOP - 09.02.09 Delinquent Medical Record Management
IHOP - 09.02.13 - UTMB Medical Record Policy
IHOP - 09.02.14 - Medical Record Retention
IHOP - 09.02.15 - Medical Record Documentation
IHOP - 09.02.16. Scanning Protected Health Information to Epic
IHOP - 09.02.18 - Processing Specimens Without a Medical Record
IHOP - 09.02.20 - Physician-Patient Email Communication
IHOP - 09.02.21 Unit History Numbe Assignment
SECTION 9.3     IHOP  -  Clinical  -  Patient Rights
IHOP - 09.03.01 - Resources Available for Patients with Disabilities
IHOP - 09.03.02 - Consent to Photograph, Video or Audio Record and or Televise Patients
IHOP - 09.03.03 - Telephone Consent for Treatment or Procedures
IHOP - 09.03.04 - Patient or Family Education
IHOP - 09.03.09 - Reporting Suspected Abuse, Neglect, and Exploitation of Children, the Elderly and or Disabled Persons
IHOP - 09.03.10 - Consent for HIV Antibody Testing and for Disclosure of Results
IHOP - 09.03.13 - Patient Rights
IHOP - 09.03.16 - Refusal of Consent or Treatment
IHOP - 09.03.17 - Consent - Overview and Basic Requirements
IHOP - 09.03.18 - Consent - Treatment of a Minor
IHOP - 09.03.20 - Universal Childhood and Adolescent Immunizations
IHOP - 09.03.21 - Consent for Sterilization
IHOP - 09.03.32 Abandoned Infant
IHOP - 09.03.33 Surgical count
IHOP - 09.03.34 Sexual Assault Examination and Collection of Forensic Evidence for the Adult, Adolescent or Pediatric Patient
IHOP - 09.03.35 Patient-Centered Communication
SECTION 9.7     IHOP  -  Clinical  -  Visitor Information
IHOP - 09.07.01 - Hospital Visitation
IHOP - 09.07.02 - Vendor Visitation - UTMB Clinical Enterprise
SECTION 9.8     IHOP  -  Clinical  -  Financial
IHOP - 09.08.02 UTMB Health Charity Care and Financial Assistance Policy
SECTION 9.11     IHOP  -  Clinical  -  Personnel Issues
IHOP - 09.11.01 - Licensure or Certification or Registration of Healthcare Professionals
IHOP - 09.11.02 - Employee Conflict with Prescribed Patient Treatment
IHOP - 09.11.04 - Standing Delegation Orders
IHOP - 09.11.05 - Physician Orders
IHOP - 09.11.06 - Criteria for Visitors from Agencies or Non-Affiliated Educational Institutions to Visit, Observe and or Participate in Patient Care at UTMB Hospitals
SECTION 9.13     IHOP  -  Clinical  -  General Clinical Procedures and Care
IHOP - 09.13.01 - Cardiopulmonary Resuscitation (CPR)
IHOP - 09.13.02 - Governance of Provider Performed Microscopy Procedures (PPMP)
IHOP - 09.13.03 - Patient-Owned Medical Equipment or Devices
IHOP - 09.13.04 - Governance of Point of Care Testing (POCT)
IHOP - 09.13.05 - Moderate Sedation (Conscious Sedation)
IHOP - 09.13.06 - Restraint Policy
IHOP - 09.13.07 - Latex Allergy or Sensitivity Management
IHOP - 09.13.08 - Interdisciplinary Plan of Care
IHOP - 09.13.09 - Interdisciplinary Admission Assessment and Reassessment of Patients
IHOP - 09.13.10 - Changing Patient Identifiers (Name and Unit History Number)
IHOP - 09.13.11 - Medical Device or Supply Recall Follow-up and Reporting
IHOP - 09.13.12 - Summary Lists for Ambulatory Patients
IHOP - 09.13.13 - Unusual Event Reporting
IHOP - 09.13.14 - Adverse Drug Events
IHOP - 09.13.15 - Serological Testing for Syphilis, Hepatitis B, and HIV During Pregnancy and Delivery
IHOP - 09.13.16 - Sentinel Events
IHOP - 09.13.18 - Disclosure of Unanticipated Outcomes
IHOP - 09.13.19 - Patient Care Alarm Systems - Maintenance, Testing and Activation
IHOP - 09.13.20 - Family Presence during Procedures and Resuscitation
IHOP - 09.13.21 - Reporting of Devices and Supplies Involved in Patient Injury, Illness, or Death
IHOP - 09.13.22 - Handling of Malfunctioning or Defective Equipment, Devices, and Supplies
IHOP - 09.13.23 - Emergency Shut-Off of Oxygen Zone Valves in UTMB Hospitals
IHOP - 09.13.24 - Patient Identifiers
IHOP - 09.13.25 - Time Out Universal Protocol for Invasive and Surgical Procedures
IHOP - 09.13.26 - Guidelines for Safe Patient Handling and Movement
IHOP - 09.13.30 -Medication Reconciliation
IHOP - 09.13.31 - Activation of the Rapid Response Team
IHOP - 09.13.32 - Infant Child Abduction
IHOP - 09.13.33 - Intraosseous Catheters
IHOP - 09.13.34 - Coordination of Resources for Transplant Patients and Living Donors
IHOP - 09.13.35 - Anticoagulation Policy
IHOP - 09.13.37 - Tube Placement for Nutrition in Adults
IHOP - 09.13.38 - Suicidal Risk Screening and Suicide Precautions
IHOP - 09.13.39 - Fall Prevention Plan
IHOP - 09.13.40 - Blanket and Fluid Warmer Operating Temperatures
SECTION 9.15     IHOP  -  Clinical  -  End of Life
IHOP - 09.15.01 - Disposition of Deceased Patients
IHOP - 09.15.05 - Patients Initiating Advance Directives
IHOP - 09.15.06 - Making and Documenting Treatment Decisions including Withholding or Withdrawing Life Sustaining Treatment
IHOP - 09.15.08 - Out-of-Hospital Do Not Resuscitate (OHDNR) Orders
IHOP - 09.15.09 - Determination of Death
IHOP - 09.15.10 Donation after Cardiac Death
SECTION 10     IHOP  -  Academic
IHOP 10.01.01 Academic Program Evaluation
IHOP 10.01.02 New Educational Program Approval Process
IHOP 10.01.03 Review of Existing Degree Programs
IHOP 10.01.04 Enrollment Policy
IHOP 10.01.05 - Credit Hours
IHOP 10.01.06 SACS-COC Substantive Change Policy
IHOP 10.02.01 Evaluation of Academic Administrators
SECTION 11     IHOP  -  Research
IHOP 11.01.03 Conduct of Clinical Research
IHOP 11.01.04 Photography of Research Animals
IHOP 11.01.06 Research Related Injury of a Subject Participating in a Clinical Investigation
IHOP 11.02.01 Institutional Office of Regulated Nonclinical Studies
IHOP 11.02.02 cGMP Manufacturing Testing Nonclinical
IHOP  -  Supporting Documents
02.06.07 - Fundraising Project Proposal Form
09.01.28 Examples of hospital areas that are not open to the public
10 2 1 Flow Diagram of New Program Approval
2.6.6 Institutional Bulletin Boards--Guidelines and Procedures
2.6.7 - Copy of Fundraising Projects Budget Worksheet
2.7.2 - Research Policy attachment to Space Mngmt Amendment
6.2.1 Authorization
6.2.1 Elements
7.1.10 Accident and Injury Report Form
7.1.20 SHP Student Grievance Steps
9.2.21 Unit History Number Assignment tips
9.2.7 Discharge Needs Assessment Factors
9.2.8 Forms Management Guidelines
9.3.9 Assessment Criteria
9.9.1 Security Associated with Offender Correctional Patients
Above Ceiling Work Permit
Accounting treatment for Cost Sharing
Acknowledgement Form Student Health Insurance
Activating the Alert System
Addendum A
Adult Primary Care Prescription Refill Guidelines for Ambulatory Services
Alternative Process for Site Marking
Anti-coagulation Follow-Up (26015)
Anti-coagulation Initial (26014)
ANTICOAGULATION DISCHARGE ORDERS (3004003)
Anticoagulation for ACS ORDER SET-No Renal Failure (CrCl greater than 30ml min) (522)
Anticoagulation for ACS ORDER SET-No Renal Failure (CrCl LESS than 30ml min) (521)
Anticoagulation for DVT PE Order Set - Renal Failure (CrCl less than 30 mL min) (524)
Anticoagulation for DVT PE ORDER SET-No Renal Failure (CrCl LESS than 30ml min) (523)
Appendix A
Appendix B
Appendix C
Appendix D
Appendix E
Asset Procedure
Authorization for Photography
Autopsy Services
BUSINESS CONTINUITY PLAN
Cellular Lease
Competent
Cover sheet re misdirected fax new logo
CRC -Log of Procedures (Muscle Biopsy)
CRC -Privilege Delineation Form (Muscle Biopsy)
Crime Prevention and Education Programs
Definitions
Definitions - Abuse Neglect and Exploitation of Elderly or Disabled Persons
Definitions of Child Abuse and Neglect
Departmental Certifications 10-10-11
Designated Operative and Invasive Procedure
Details IHOP 6.3.9 Outpatient ABN
Disposable Income Worksheet
Do's and Don'ts of Scanning
DOT behavior sheet
DSHS Clean 11032009-Texas_HIV Testing in Pregnancy Recommendations
Email Agreement
Email Tracking Tool
Enteral feedings for Adults (9.13.37)
entertainment chart
expenditure
Express in-service - Falls-IHOP 2-3
Facsimile Cover Letter new logo
Faculty CV template
FACULTY OMBUDSPERSON POSITION DESCRIPTION
Faculty or Staff Organization Registration Form
FAIR USE definition
Federal Poverty Index
FINANCIAL CLASSIFICATION OF P AND V
Financial Indigent Requirements and Application Process
Fire Alarm Response
Fire Drills
Fluid Warming Guidelines
FOAM Guidelines re Signage
GNL Photography Policy
Guidelines for copying pasting attachment (IHOP - 9 2 15 - Medical Record Documentation)
Guidelines for Registered Faculty or Staff Organizations
GYN ONC Clinical Trials
HBConfirmation
HBsAg_screening
Health System Departmental Certifications
Hotel Tax Exempt Certificate
Humpty Dumpty Fall Assessment Scale
IBS definition
ICC Repeal Request
IHOP 5 7 5 Assessment, Inquiry and Investigation Procedures Manual
IHOP - 9 2 15 - Medical Record Documentation - style guide
IHOP 03.07.08 - LACTATION ROOM Guidelines
IHOP 05.03.08 Grievance Panel Hearing Procedures
IHOP 07.01.01 Student Request for Accommodations
IHOP 09.1.32 Process for Testing Dr. Pink System
IHOP 10 1 1 Critical Thinking
IHOP 2.17.7 Wikipedia Examples
IHOP 6 2 1 Authorization Validation Checklist
IHOP 6 2 24 Form- Request for Use of PHI Offsite
IHOP 7 1 13 Documentation of Non Academic Concerns Form
IHOP 7 1 20 SHP Grading and Evaluation
IHOP 7.1.1 - School of Nursing Essential Functions
IHOP 7.1.3 Documentation of Non Academic Concerns
IHOP 9 13 10 - Changing Patient Identifiers - Attachment A
IHOP 9 13 10 - Changing Patient Identifiers - Attachment B
IHOP 9 13 10 - Changing Patient Identifiers - Attachment C
IHOP 9 13 10 - Changing Patient Identifiers - Attachment D
IHOP 9.11.4 Standing Delegated Order Flow Diagram
IHOP 9.13.10 Changing Patient Identifiers
IHOP 9.13.22 Medical Equipment Plan (EOC) Master_Plan
IHOP 9.13.32 Admission Decision Tree
IHOP 9.13.32 Exclusion Criteria1
IHOP 9.13.32 Inclusion Criteria
IHOP 9.13.36 OSA Screening Tool
IHOP 9.13.4 POCT Responsibilities
IHOP 9.2.20 Email Agreement
IHOP 9.2.8 Medial Record Forms Management Guidelines doc 2007
IHOP 9.3.32 SBS Medical_Disclosure_English
IHOP 9.3.32 SBS Medical_Disclosure_Spanish
IHOP 9.3.4 Law Enforcement Request for Records (SANE)
IHOP 9.3.4 Texas Department of Family and Protective Services p1
IHOP 9.3.9 Assessment Criteria
IHOP 9.3.9 Examples LINK
IHOP Policies that delineate professional behavior
IHOP process
IHOP Process Diagram-Visio
IHOPdiagram
Illegal Drugs and Alcohol Use and Abuse
IncomeCalculationDocWorksheet
IncomeTaxProc
Inpatient Nursing Admission Assessment- Criteria for further assessment (4)
Intraosseous (IO) Overview
IP HEM ARGATROBAN WEIGHT-BASED DOSING FOR HIT (3000090)
LD Access Request Form
Longevity Pay Schedule
MED-REQ9.2.6
MediaAuthorization
MediaAuthorizationSpan
Medical Examiner
Medical Indigency worksheet
Medically Indigent Notification Letter
Month income calculation
Morse Fall Assessment Scale
OCRLetterviolence-1
Off unit log
OGG feedback re IHOP 8.1.2 Safe Patient Handling
Outbreak of Hep A
Pager Lease
PASS
Patient dismissal letter A14
Patient Owned Medical Equipment CES form
PATIENT PLACEMENT FORM
Patient Services Complaint Process 2009
PG-Priority Index Definition
Policy Template
Postmortem Anatomical Gifts
PP COBRA Premiums Paid by UTMB
Pre-existing Conditions of Primary Interest
Procedure for Clinical Assessment of Brain Death
Professionalism Agree Final
RACE
Reduction in Force Guidelines
Registration for Eligibility of 3rd party Resources
Release of Forensic Photographs
Request for Dual Employment
Request for Non-IHOP Review
Request for Policy Review
Request for Use of PHI Offsite
research request form9.2.6
Resource Conservation Guidelines
Restraint Comparison Table
Restraint Algorithms
Reversal of Anticoagulation-No indications for SQ administration of Vitamin K (525)
RIF Criteria
RIF Guidelines
RIFGuidelines
RMCHP 13. 7 Domestic Violence
Roles and Responsibilities - Deceased Patients
RTOG Active and Pending Protocols CAMPUS
Screening Criteria for Communicable Diseases
Sexual Assault Prevention and Response
skin to skin
Space Planning Process (2013)
Space Request Process and Form_Nov2012_v3 (4)
Style Guide (IHOP - 9 2 15 - Medical Record Documentation)
SUBCHAPTER C Texas Public Information Act Exceptions
Supervisor's Observation Report
Sustainability Steering Committee Report
TDP3 4BDonorVerificationForm
Telecommunications Services Request
Texas Administrative Code CHAPTER 21 Student Services
The certification process
Timely Warnings, Emergency Notifications and Evacuations
Tips for Social Media
Toluidine Blue Dye
TRAUMA TEAM ACTIVATION GUIDELINES
UT SYSTEM POLICY ON SUSTAINABILITY PRACTICES-Assignments
UTMB Campaign Counting Guidelines
UTMB Health authorization for the release of photos
UTMB Health consent to photograph for TPO
UTMB Healthcare Buildings
UTMB Patient Absence Request Form 05PA
UTMB SPACE GUIDELINES
Vendor Procedures
Vendor Release Form
Vendor Visitation Form
Verification Letter Various Scrubs
Verifying Treatment Relationship Checklist
Victory Lakes Surgical Center Consent Form
Violation of Policy paragraph
Who Are UTMBs Campus Security Authorities
Witnesses

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