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[] |