Institutional Handbook of Operating Procedures Table of Contents

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.


 


Table of Contents

Policy Title Category
IHOP - 09.01.02 - Management of Patient Belongings SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.04 - Patient Transportation SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.08 - Inpatient Absence for Personal or Therapeutic Reasons SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.10 - Admission, Discharge, and Transfer - Neonatal Nurseries SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.12 - Intrafacility and Interfacility Transfer of Patients Policy SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.13 - Discharge Planning SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.14 - Patient Discharge SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.16 - Admission of Interfacility Transfer Patients SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.17 - Medicare Discharge Appeal Process SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.18 - Letter of Financial Responsibility for Continued Care for Non-Medicare and Non-Medicaid Patients SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.21 - Examination and Treatment for Emergency Medical Conditions and Women in Labor (EMTALA) SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.22 - Determining Hospital and Emergency Department Saturation Status SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.23 - MICU CCU Admission Criteria SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.24 - Admission Discharge Criteria for Day Surgery Unit (DSU) SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.25 - Admission, Discharge, and Transfer - NCCU SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.26 - Admission Discharge Transfer Criteria to SICU SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.29 - Admission, Discharge, and Transfer Criteria- PACU SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.01.30 - Opening, Closing, or Transferring an Inpatient Unit SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP 09.01.09 - Delayed Discharge of Newborns SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP 09.01.15 - Adoption From Nurseries SECTION 9.1: Clinical - Admission, Discharge and Transfer 20 System.Byte[]
IHOP - 09.02.01 - Management of UTMB's Protected Health Information (PHI) SECTION 9.2: Clinical - Patient Records 21 System.Byte[]
IHOP - 09.02.03 - Retiring Incomplete Records SECTION 9.2: Clinical - Patient Records 21 System.Byte[]
IHOP - 09.02.06 - Medical Record Access SECTION 9.2: Clinical - Patient Records 21 System.Byte[]
IHOP - 09.02.07 - Use and Disclosure of Inpatient Protected Health Information SECTION 9.2: Clinical - Patient Records 21 System.Byte[]
IHOP - 09.02.09 - Delinquent Medical Record Management SECTION 9.2: Clinical - Patient Records 21 System.Byte[]
IHOP - 09.02.13 - UTMB Medical Record Policy SECTION 9.2: Clinical - Patient Records 21 System.Byte[]
IHOP - 09.02.14 - Medical Record Retention SECTION 9.2: Clinical - Patient Records 21 System.Byte[]
IHOP - 09.02.15 - Medical Record Documentation SECTION 9.2: Clinical - Patient Records 21 System.Byte[]
IHOP - 09.02.16 - Scanning Protected Health Information to Epic SECTION 9.2: Clinical - Patient Records 21 System.Byte[]
IHOP - 09.02.18 - Processing Specimens Without a Medical Record SECTION 9.2: Clinical - Patient Records 21 System.Byte[]
IHOP - 09.02.20 - Physician-Patient Email Communication SECTION 9.2: Clinical - Patient Records 21 System.Byte[]
IHOP - 09.02.21 - Medical Record Number Assignment SECTION 9.2: Clinical - Patient Records 21 System.Byte[]
IHOP 09.02.08 - Medical Record Forms Management SECTION 9.2: Clinical - Patient Records 21 System.Byte[]
IHOP - 09.02.15 - Medical Record Documentation SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.01 - Resources Available for Patients with Disabilities SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.02 - Use of Photograph, Video Audio Recordings and or Televising Patients SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.03 - Telephone Consent for Treatment Procedures SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.04 - Patient Family Education SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.05 - Patient Grievance Policy SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.09 - Reporting Suspected Abuse, Neglect, and Exploitation of Children, the Elderly and or Disabled Persons SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.10 - Consent for HIV Antibody Testing and for Disclosure of Results SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.13 - Patient Rights and Responsibilities SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.16 - Refusal of Consent or Treatment SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.17 - Consent - Overview and Basic Requirements SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.18 - Consent - Treatment of a Minor SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.20 - Universal Childhood and Adolescent Immunizations SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.21 - Consent for Sterilization SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.32 - Abandoned Infant (Baby Moses) Policy SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.34 - Sexual Assault Examination and Collection of Forensic Evidence for the Adult, Adolescent or Pediatric Patient SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.03.35 - Patient-Centered Communication SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP 09.03.14 - Service Animals SECTION 9.3: Clinical - Patient Rights 22 System.Byte[]
IHOP - 09.07.01 - Hospital and Ambulatory Services Visitation SECTION 9.7: Clinical - Visitor Information 23 System.Byte[]
IHOP - 09.07.02 - Vendor Management Policy SECTION 9.7: Clinical - Visitor Information 23 System.Byte[]
IHOP - 09.07.04 - Minors in the Workplace SECTION 9.7: Clinical - Visitor Information 23 System.Byte[]
IHOP - 09.08.02 - UTMB Health Charity Care and Financial Assistance Policy SECTION 9.8: Clinical - Financial 24 System.Byte[]
IHOP - 09.11.01 - Licensure Certification Registration of Healthcare Workers SECTION 9.11: Clinical - Personnel Issues 26 System.Byte[]
IHOP - 09.11.02 - Employee Conflict with Prescribed Patient Treatment SECTION 9.11: Clinical - Personnel Issues 26 System.Byte[]
IHOP - 09.11.03 - Dress Code and Uniform Policy SECTION 9.11: Clinical - Personnel Issues 26 System.Byte[]
IHOP 09.11.04 Standing delegation orders SECTION 9.11: Clinical - Personnel Issues 26 System.Byte[]
IHOP 09.11.05 - Physician Orders SECTION 9.11: Clinical - Personnel Issues 26 System.Byte[]
IHOP 09.13.47 - Massive Transfusion Protocol SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.01 - Cardiopulmonary Resuscitation (CPR) SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.02 - Governance of Provider Performed Microscopy Procedures (PPMP) SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.03 - Patient-Owned Medical Equipment Devices SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.04 - Governance of Point of Care Testing (POCT) SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.05 - Procedural Sedation (Moderate and Deep Sedation) SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.06 - Initiating and Monitoring Restraints SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.07 - Latex Allergy Sensitivity Management SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.08 - Interdisciplinary Plan of Care SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.09 - Interdisciplinary Admission Assessment and Reassessment SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.10 - Changing Patient Identifiers (Name and Unit History Number) SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.11 - Manufacturer, Distributor, and FDA Recall Policy SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.12 - Summary List for Ambulatory Patients SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.13 - Unusual Event Reporting SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.14 - Adverse Drug Events SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.15 - Serological Testing for Syphilis, Hepatitis B, and HIV During Pregnancy and Delivery SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.16 - Sentinel Events SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.17 - Minimal Sedation (Anxiolysis) of Pediatric Patients SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.19 - Patient Care Alarm Systems Maintenance, Testing, and Activation SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.20 - Family Presence During Procedures and Resuscitation SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.21 - Reporting of Devices and Supplies Involved in Patient Injury, Illness, or Death SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.22 - Handling of Malfunctioning or Defective Equipment, Devices, and Supplies SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.23 - Emergency Shut-Off of Piped Medical Gas Zone Valves in UTMB Hospitals SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.24 - Patient Identifiers SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.25 - Universal Protocol for Invasive and Surgical Procedures SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.26 - Guidelines for Safe Patient Handling and Mobility (SPHM) SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.27 - UTMB Surgical Devices and Implants Utilization SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.28 - Surgical Counts SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.30 - Medication Reconciliation SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.31 - Activation of the Medical Surgical Rapid Response Team (RRT) SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.32 - Infant Child Abduction Response Policy for Inpatient Areas SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.33 - Intraosseous Catheters SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.34 - Coordination of Resources for Transplant Patients and Living Donors SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.37 - Tube Placement for Nutrition in Adults SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.40 - Blanket and Fluid Warmer Operating Temperatures SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.41 - Child Life Specialist Referrals for Trauma Patients SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.42 - Tissue and Bone Procurement Storage and Distribution SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.43 - Adminstration of Continuous Infusions of Intravenous Neuromuscular Blockade SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.44 - Activation of the Obstetrical (OB) Emergency Notification System SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.48 - Management of Nitronox for Analgesia on the Blocker Burn Unit SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.13.49 - Social Work Consult SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP 09.13.18 - Disclosure of Unanticipated Outcomes SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP 09.13.29 - Transfusion of Blood Components Adults and Pediatrics SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP 09.13.36 - Reporting of Critical Results to Providers SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP 09.13.38 - Suicide Risk Screening and Suicide Precautions for Patients SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP 09.13.39 - Patient Falls Prevention Plan SECTION 9.13: Clinical - General Clinical Procedures and Care 27 System.Byte[]
IHOP - 09.14.00 - 340B Drug Pricing Program Plan SECTION 9.14: Clinical - Pharmacy 157 System.Byte[]
IHOP - 09.14.01 - Covered Entity Eligibility for the 340B Drug Pricing Program SECTION 9.14: Clinical - Pharmacy 157 System.Byte[]
IHOP - 09.14.04 - Prevention of Duplicate Discounts in the 340B Drug Pricing Program SECTION 9.14: Clinical - Pharmacy 157 System.Byte[]
IHOP - 09.14.05 - Roles and Responsibilities in the 340B Drug Pricing Program SECTION 9.14: Clinical - Pharmacy 157 System.Byte[]
IHOP - 09.14.06 - Education and Competency in the 340B Drug Pricing Program SECTION 9.14: Clinical - Pharmacy 157 System.Byte[]
IHOP - 09.14.08 - Contract Pharmacy Operations in the 340B Drug Pricing Program SECTION 9.14: Clinical - Pharmacy 157 System.Byte[]
IHOP - 09.14.09 - Contract Pharmacy Oversight in the 340B Drug Pricing Program SECTION 9.14: Clinical - Pharmacy 157 System.Byte[]
IHOP - 09.14.10 - Noncompliance and Material Breach in the 340B Drug Pricing Program SECTION 9.14: Clinical - Pharmacy 157 System.Byte[]
IHOP - 09.14.11 - Compliance, Monitoring, and Reporting in the 340B Drug Pricing Program SECTION 9.14: Clinical - Pharmacy 157 System.Byte[]
IHOP - 09.14.12 - Vendor Compliance with UTMB Information Resources in the 340B Drug Pricing Program SECTION 9.14: Clinical - Pharmacy 157 System.Byte[]
IHOP - 09.14.13 - Use of 340B Drugs and Maintenance of Auditable Records During Emergency Operations Status SECTION 9.14: Clinical - Pharmacy 157 System.Byte[]
IHOP 09.14.02 - Enrollment, Recertification, and Change Requests in the 340B Drug Pricing Program SECTION 9.14: Clinical - Pharmacy 157 System.Byte[]
IHOP 09.14.03 - Patient Eligibility for the 340B Drug Pricing Program SECTION 9.14: Clinical - Pharmacy 157 System.Byte[]
IHOP 09.14.07 - Inventory Management in the 340B Drug Pricing Program SECTION 9.14: Clinical - Pharmacy 157 System.Byte[]
IHOP - 09.15.05 - Patients Initiating Advance Directives SECTION 9.15: Clinical - End of Life 28 System.Byte[]
IHOP - 09.15.06 - Making and Documenting Treatment Decisions including Withholding or Withdrawing Life-Sustaining Treatment SECTION 9.15: Clinical - End of Life 28 System.Byte[]
IHOP - 09.15.07 - DNR Orders in the Operating Room and Peri-Operative Period SECTION 9.15: Clinical - End of Life 28 System.Byte[]
IHOP - 09.15.08 - Out-of-Hospital Do Not Resuscitate (OOHDNR) Orders SECTION 9.15: Clinical - End of Life 28 System.Byte[]
IHOP - 09.15.09 - Determination of Death SECTION 9.15: Clinical - End of Life 28 System.Byte[]
IHOP - 09.15.11 - COVID-19 End Of Life Preparing Body SECTION 9.15: Clinical - End of Life 28 System.Byte[]
IHOP 09.15.01 - Disposition of Deceased Patients SECTION 9.15: Clinical - End of Life 28 System.Byte[]
IHOP 09.15.10 - Donation after Cardiac Death SECTION 9.15: Clinical - End of Life 28 System.Byte[]