Policies Manual

         Table of Contents [PDF]

For keyword searches, use Control-F.

Policies Regarding Admissions / Dispositions

34.6   Admission of Hip Fracture Patients from the Emergency Department [PDF]

34.8   Admission of Patients with Diabetes Mellitus and Foot Ulceration or Infection [PDF]

34.3   Admissions to Medicine [PDF]

34      Admitting Policy [PDF]

34.1   ED Attending Authority to Admit [PDF]

10      ED Referrals to OPD Clinics for Follow-up [PDF]

67.1   Emergency Discharge Policy [PDF]

6        Employee Health Service Referrals [PDF]

4.3     Inter-Institutional Transfer of Patient [PDF]

10.1   Referral to Clinics for Initial Treatment [PDF]

8        Return of a Discharged Patient by a Placement Facility [PDF]

34.2   Responsibility of ED Attending to Primary Attending [PDF]

38.0   Transport of Emergency Department Patients [PDF]

34.5   ICU Consults and Admissions[PDF]

45      Procedures Which May Not Be Performed in the ED [PDF]

Policies regarding Consultations / Interactions with Other Departments

34.7   Initial Care of Pregnant Patients Presenting to the Hospital [PDF]

35      OR Availability [PDF]

20.6   Emergency Department and Inpatient ophthalmology consults [PDF]

20.7   Hyperemisis of Pregnancy Consult Protocol [PDF]

58.1   Endoscopy in the PER [PDF]

58      Endoscopy, Adult [PDF]

62      Ocular Emergencies [PDF]

21      Psychiatric Evaluation in the Emergency Department [PDF]

21.1   Psychiatric Patient Transport from Psych Clinic to ED [PDF]

22      Radiology Services [PDF]

61.3   Registration and Handling of Stillborns in the ED [PDF]

61.2   Registration of Mother and Live Newborns in ED [PDF]

45      Procedures Which May Not Be Performed in the ED [PDF]

Medical Protocols

42.3   AER Asthma Protocol and Standing Orders [PDF]

49      Alcoholism Protocol [PDF]

56      Care of the Diabetic Patient [PDF]

28      Death Management Protocol [PDF]

47.1   EKG Transmission and Interpretation [PDF]

52      Ischemic Chest Pain Protocol [PDF]

44      Immunizations-Pediatric Emergency Room [PDF]

60.1   Infection Control - Tuberculosis Identification/Management [PDF]

60      Infection Control Guidelines [PDF]

62      Ocular Emergencies [PDF]

24.3   Laboratory Services for Poisoning Overdose Ingestion [PDF]

61.1   Management of Mother and Newborn in ED [PDF]

64.1   Multiple Trauma - Early Management [PDF]

63      Management of Poisonings [PDF]

41.2   Obtaining Narcotics / Controlled Drugs from AER for Radiology [PDF]

56.1   Protocol for Administration of C1-Inhibitor (CinrzyeTM) to Patients with Hereditary Angioedema (HAE) [PDF]

52.1   Protocol for the Initial Evaluation and Management of Patients with Ischemic or Hemorrhagic Stroke [PDF]


Medical Protocols Concerning Environmental Emergencies / Bites

50      Animal Bites and Wounds [PDF]

50.1   Monkey Bite Protocol [PDF]

59.1   Exposure to Hazardous Materials [PDF]

59      Management of Exposure to Blood/Body Fluids [PDF]

51      Burns - Initial Management [PDF]

Medical Protocols Concerning Special / At-Risk Populations

26.2   Elder/Institutional Abuse [PDF]

26.3   Domestic Violence [PDF]

26.1   Management of Suspected Child Abuse or Neglect [PDF]

26.4   Sexual Assault Protocol (Code 11) [PDF]

Policies Regarding Diversion / EMS / Disasters

7.2     EMS Diversion Protocol [PDF] (Diversion Form) [PDF]

7.1     EMS Exchange Requirements with Pre-Hospital Personnel [PDF]

5        Emergency Preparedness Plan (EPP) [PDF]

5.1     Emergency Response for Medical Center [PDF]

5.2     Overcrowding and SURGE Management Plan [PDF]

7        Pre-Hospital Care from EMS and Others [PDF]

4.1     Relationship with Specialized Referral Center - EMS Advisory [PDF]

61.5   Peds ED to Clinic Diversion [PDF]

Nursing Policies

40.1   Guidelines for Nursing Orders on Admitted Patients [PDF]

39.3   Nursing Triage Assessment Guidelines [PDF]

41      Medication Administration by ED Personnel [PDF]

46      Saline Locks [PDF]

38      Standards for Nursing Care and Vital Signs [PDF]

39      Triage and Retriage of AER and PER Patients [PDF]

39.2   Triage of Direct Admission [PDF]

39.1   Triage of Psychiatric Emergency Patients [PDF]

40      Protocol for Nurse Initiated Laboratory Studies in Treatment Area [PDF]

23      Restraints and Locked Seclusion [PDF]

40.2   ED Nurse Initiated Pain Protocol [PDF]

Technicians / BAs / Registrar Policies

47      EKG Request and Performance of 12 Lead EKG's [PDF]   

23.2   Constant Observation of Patients [PDF]

10.3   Telephone Tree for ED Registrars [PDF]

61.4   Registration of an ED Patient [PDF]

Job Descriptions / Roles / Employee Expectations

18      Role of Emergency Department Attending [PDF]

6.1     Toxicology Testing of Employees in the ED [PDF]

Policies Concerning Patient Consent & Rights / Social Services / Telephone Encounters

12.1   Acknowledgment of Receipt of Notice of Privacy Practices [PDF]

12      Confidentiality of Patient Information [PDF]

14      Consent, Adults [PDF]

67.2   Discharge Against Medical Advice [PDF]

67      Discharge of Patient from the ED [PDF]

67.3   Discharge of Undomiciled Patients [PDF]

16      DNR [PDF]

15      Health Care Proxy [PDF]

26.5   ED Policy for Digital Photography [PDF]

17      Organ Donor Policy [PDF]

27      Patient Grievance Mechanism [PDF]

31      Patient Property, Care of [PDF]

39.3   Undomiciled/ homeless care in the ED [PDF]

32      Visiting Policy [PDF]

48.1   Recall of Patients with Missed Fractures / X-Ray Interpretation [PDF]

48      Recalls and Reportable Diseases [PDF]

10.2   Telephone Advice in the ED [PDF]

30      Security-Police Intervention [PDF]

26      Social Work Services in the ED [PDF]

29      Interpreteam - Language Translation and Interpreter Service [PDF]

26.2   Elder Abuse [PDF]

Policies Regarding the Handling of Blood / Specimen / Lab Equipment

25      Location, Storage and Procurement of Blood Supplies [PDF]

33.1   Equipment Maintenance [PDF]

24.4   Gem 3000 Point of Care Blood Analysis [PDF]

24.1   Laboratory Alert Values [PDF]

24      Laboratory Services [PDF]

24.2   Surgical Specimen Handling [PDF]


3        Emergency Care Services at Mount Sinai - General Statement [PDF]

13      Medical Record and Reports [PDF]

13.1   Medical Record Forms - Other [PDF]

13.2   Maintenance of Medical Record [PDF]

3.2     Mission Statement [PDF]

3.3     Vision Statement [PDF]

1        Table of Organization [PDF]

          ED - Table of Organization [PDF]