This Manual is Maintained by Frank Rosen, HCQ

Administration (ADM)
ADM-01 Policy, Procedure, Guideline & Directive (PPGD) Sponsorship & Approval
ADM-02 Industry Representative Code of Conduct
ADM-02 Attachment A: Vendor Representative Classification
ADM-02 Attachment B: Minimum Credential Requirements
ADM-03 Adverse Event Reporting
ADM-04 Information Systems Department ("BIDMC-IS") Data Security Policy
ADM-06 Medical Record Revision & Approval of New or Revised Forms
ADM-06 Appendix A: Guidelines/Standards in Form Development
ADM-06 Appendix B: BIDMC Forms Standards & Guidelines for Development
ADM-06 Appendix C: Application for Medical Record Form Approval
ADM-06 Appendix D Process for Use of Abbreviations on Medical Record Forms
ADM-06 Appendix E: Form Approval Process Flowchart
ADM-07A Policy on Journalist and News-Related Media Relations and Communications, Including Request
ADM-07B Policy on Commercial and Non-News Media Relations and Communications, Including Request
ADM-08 Financial Assistance
ADM-12 BIDMC Portal/Web Directory
ADM-14 Signature Authorization
ADM-14 Attachment A: Signature Auth. Matrix
ADM-14 Attachment B: Contract Term Sheet
ADM-14 Attachment C: Signature Auth. Form
ADM-15 Supplier Contact and Negotiation
ADM-16 Code Help - Emergency Department Saturation/Gridlock Response Plan
ADM-16 Appendix A: Code Help Levels
ADM-17A Personal Gifts, Travel, Meals, and Entertainment
ADM-17B Industry-Supported Speaking, Programs, Fellowships, and Preceptorships
ADM-18 Conflict of Interest Policy for Institutional Transactions
ADM-19 Conflict of Interest Policy for Research
ADM-20 Clinical Approval Process for Elective Services
ADM-23 Hospital Call Center Telephone Recording
ADM-24 A Medical Records – Ambulatory Completion Requirements
ADM-24 B Medical Records – Inpatient Completion Requirements
ADM-26 Records Management Policy
ADM-26 Attachment A : Record Retention & Disposition Manual
ADM-26 Attachment B Record Retention and Disposition Schedule
ADM-27 Identity Theft Prevention Policy
ADM-28 Reporting and Notification of Breaches of Patient Health Information and Personally Identifi
ADM-29 Public Policy Advocacy, Political Campaigns, Contributions to Public
ADM-30 Reporting, Investigation, and Resolution of Compliance Issues
ADM-31 Restrictions on Offering or Providing Free or Discounted Goods and Services to Patients
ADM-32 Policy Regarding Raffles Held by BIDMC
ADM-32 Exhibit 1: Raffle Notification Form
ADM-32 Exhibit 2: W-9 and Instruction Form
ADM-32 Exhibit 3: Tax Department Raffle Questionnaire
ADM-32 Exhibit 4: Raffle Memorandum
ADM-33 Web-based Staff Training Modules and Tracking Tools: Sponsorship, Formulation, Approval and I
ADM-34 Copy and Paste of Clinical Documentation
ADM-35 Antitrust Policy
ADM-36 Criteria for the Elimination of Select Paper Copies of PMR and DRS Documents
ADM 36 Attachment A: Elimination of Paper Copy Worksheet
ADM-38 Compliance Audit and Monitoring
ADM-40 False Claims and Payment Fraud Prevention
ADM-41 Government Interactions Policy
ADM-42 Compliance Helpline Policy
ADM-44 Exclusion Checking Policy
ADM-45 Reporting and Refunding of Overpayments
ADM-46 OpenNotes: Offering Patients Online Access to Clinical Notes
ADM-47 Clinical Quality Value Analysis (CQVA) Policy and Procedure
ADM-48 After Hours GI Procedures
ADM-49 Management of Drug Shortages Affecting Patients Receiving Care at BIDMC
ADM-49 Attachment A: Drug Shortage Management Algorithm
ADM-50 Enterprise PACS & Imaging Data Quality Policy
ADM-51 Visiting Industry Scientists - Attendance at Educational Conferences
ADM-52A Marketing, Logo Usage and Website Policies
ADM-52B Social Media Policies
ADM-53 Compliance Review of Modifications to Medicare Fee for Service Claims
ADM-54 Contract Management Policy
ADM-54 Attachment A: Evaluation of Contracted Services Form
ADM-55 Physician/Referral Source – Space & Equipment Lease Compliance Policy
ADM-56 Telecommunications Pager Use Policy
ADM-57 Managing Prescriptions Generated in Ambulatory Services at BIDMC
ADM-58 Observers at BIDMC
ADM-59 Use of Medical Scribes
ADM-60 The Use of Modifier 59 and Sub-modifiers XE, XP, XS, XU
ADM-61 Clinical Documentation Query Policy
ADM-62 Consulting, Speaking, and Other Outside Activities
ADM-63 The Use of Modifier 25
ADM-64 Gift Acceptance Policy
ADM-65 Management of Product and Supply Shortages Directly Affecting Patient Care at BIDMC
ADM-65 Attachment A: Shortage Management Algorithm
ADM-66 Photography for Clinical Care
ADM-67 BIDMC Call Center Live Monitoring/Service Observing of Recorded Agents
ADM-68 340B Policy and Procedure
ADM-69 Collaborative Drug Therapy Management

Patient Rights (PR)
PR-02 Informed Consent and Decision Making Policy
PR-02 Appendix A: RSC-02: Consent of a Pregnant Patient for Radiological Procedures
PR-02 Appendix B: Algorithm for Identifying a Surrogate Decision-Maker
PR-02 Appendix C: BIDMC Advance Care Planning Guideline
PR-03 Grievance and Patient Complaints
PR-04 Patients' Rights
PR-05 Withholding, Withdrawing or Limiting Life-Sustaining Treatment including Resuscitation
PR-06 Blood or Blood Product Refusal
PR-07 HIV Testing and Documentation
PR-08 How to Conduct a Patient Search
PR-09 Organ and Tissue Donation Protocol
PR-10 Care of Patients Under Legal or Correctional Restrictions
PR-11 Mandatory Reporting of Alleged Abuse and Neglect
PR-11 Attachment A : Child Protection Procedure
PR-11 Attachment B: Child Abuse Report
PR-11 Attachment C: Elder Protection Procedure
PR-11 Attachment D: Elder Abuse Mandated Reporter Form
PR-11 Attachment E: Fax Report Incident/ Abuse Form
PR-11 Attachment F: Disabled Persons Protection Procedure
PR-11 Attachment G: Disabled Persons Report Form
PR-11 Attachment H: Accounting of Disclosures Tracking Tool
PR-12 Guidelines for Determining Brain Death
PR-13 Donor after Circulatory Determination of Death (DCDD)
PR-14 Identification and Response to Domestic Violence Victims
PR-16 Autopsy Protocol and Consent
PR-17 Interpreter Services
PR-18 Advance Directives
PR-19 Suspected Patient Abuse, Neglect or Harassment in the Medical Center
PR-20 Organ and Tissue Donation Protocol for Fetal and Neonatal Deaths
PR-21 Visitation Policy for Family Members and Visitors
PR-22 Procedure to include the Voluntary Non-Opioid Directive (VNOD) in a Patient’s Medical Record
PR-22 Appendix A: Voluntary Non-Opioid Directive Form
PR-22 Appendix B: How Do I Get Something Scanned?

Care of Patients (CP)
CP-03 Moderate Sedation Non-Anesthetist (formerly Conscious Sedation)
CP-06 Employee Request To Not Participate in Care Delivery
CP-08 Pharmacists’ Medication Order Clarification/Escalation
CP-10 Controlled Substance Management on Nursing Units
CP-11 Drug Sample Management
CP-15 Clinical Emergency Team Response
CP-16 Latex Sensitivity in the Environment
CP-17 Reporting a Death and Disposition of Remains
CP-19 Intra Campus Ambulance Transfers
CP-20 Use of Medical Abbreviations (Approved and Prohibited)
CP-20 Attachment A: BIMDC Approved Abbreviation List
CP-20 Attachment B: Prohibited Abbreviation List
CP-21 Patient Identification
CP-21- Appendix A Correcting Misidentified Patients
CP-22 Patient Identification Band Application
CP-23 Safe Handling of Patient Valuables, Belongings and Patient Essentials
CP-24 Controlled Substances Surveillance
CP-25 Oral Communication of Critical Test Results
CP-26 Policy on Interventions that are Ineffective orHarmful
CP-27 Physician Responsibility for Diagnostic Test Results
CP-28 Use of Restraints and/or Seclusion
CP-29 Inpatients Leaving the Unit
CP-31 Urgent or Emergent Transfer of Inpatient to Another Tertiary Facility
CP-32 Medication and Solution Labeling for Use in Procedural Settings on or off the sterile field
CP-33 Non-Operative Universal Protocol Policy
CP-34 Invasive Procedure Definition
CP-35 Safe Bed Policy
CP-36 Medication Reconciliation
CP - 37 Pet Therapy Program
CP-39 First Aid Response
CP-40 "Code Blue"/Cardiac Arrest Response
CP-41 Acute Management of Sexual Assault Victims
CP-44 Patients Discharged to Another Facility from BIDMC Inpatient Units
CP-45 Discharge Planning
CP-46 Patients Leaving Before or During Evaluation or Treatment and/or Against Medical Advice
CP-46 Appendix A: Patients Leaving....Decision Tree
CP-47 Guidelines for Perioperative Screening and Management of Patients with Obstructive Sleep Apnea
CP-48 Warmed Storage of Blankets, Parenterals and Irrigation Solutions
CP-49 Management of Patients with a Self-Administering Insulin Pump
CP-50 Inpatient Seasonal Influenza Vaccination
CP-51 Patient-to-Patient Blood or Body Fluid Exposure Management
CP-52 Deep Sedation
CP-53 Obstetrical Emergencies
CP-54 Psychiatric Emergency (Code Purple)
CP-55 Anesthesia STAT
CP-56 STAT Surgical Airway
CP-57 Monitoring Guidelines for Non-Perioperative Patients with Obstructive Sleep Apnea or
CP-58 Interventional Procedures Rapid Response Policy
CP-59 Specimen Tracking Policy for Procedures outside of the Operating Room
CP-60 Fasting Recommendations for Patients Receiving Sedation or Anesthesia
CP-61 Inpatient Stroke Stat
CP-62 Outside Hospital or Facility Transfer Policy
CP-63 Policy for Appropriate Use of Vendor-Laundered Scrubs
CP-64 Use and Handling of Medical and Non-Medical Marijuana

Environment of Care (EOC)
EOC-01 Expiration Date Management of Materials and Supplies
EOC-02 Safety Management Plan
EOC-03 Hazardous Materials and Waste Management Plan
EOC-04 Life Safety/ Fire Safety Management Plan
EOC-05 Utilities Management Plan
EOC-06 Medical Equipment Management Program
EOC-07 Security Management Program
EOC-08 Emergency Management Program Policy
EOC-09 Employee Work-Related Accident, Injury or Exposure Reporting
EOC-10 Blood or Body Fluid Exposure Management
EOC-10 Attachment A: Injury/BBF Reporting and Care for BIDMC Off Site Locations
EOC-11 TB Exposure and TB Exposure Management
EOC-15 Possession and Handling of Firearms/Dangerous Weapons
EOC-16 No Smoking
EOC-17 Electrical Appliance Safety
EOC-18 Authority and Jurisdiction of BIDMC Police Officers
EOC-19 Use of Firearms-BIDMC Police Officers
EOC-20 Use of Force by BIDMC Police and Public Safety Officers
EOC-21 Use of Force Reporting and Reviews - BIDMC Police Officers
EOC-22 Authorized Non-Lethal Weapons
EOC-23 Fitness for Duty - BIDMC Police Officers
EOC-24 Use of Force Training for BIDMC Police and Public Safety Officers
EOC-25 Storage, Maintenance and Control of Public Safety Department Equipment, Weapons and Firearms
EOC-27 Product, Pharmaceutical and Device/Alert Notification
EOC-28 Infection Control/Hospital Epidemiology (IC/HE) and Employee Occupational Health Services (EO
EOC-29 Laser Safety Program
EOC-30 Personal Protective Equipment Program
EOC-31 BIDMC Identification and Access Cards
EOC-32 Weapons Related Threat Response Plan- CODE SILVER
EOC-33 Sharps Safety: Exemption from Use of Devices with Sharps Injury Prevention Technology
EOC-34 Managing Clinical Alarms of Patient Care Devices
EOC-35 Use and Management of Patient-Provided Medical Equipment in the Inpatient Setting

Personnel Management (PM)
PM-01 Employee Training and Education
PM-02 Employee Appeal Process
PM-03 Employee Paid Time Off (PTO)
PM-04 Corrective Action
PM-05 Employee Responsibilities in Medical Center Emergency Situations
PM-06 Violence Prevention and Reporting Policy
PM-07 Employee Dependability (Attendance & Tardiness) Expectations
PM-08 Employee Performance Reviews and Performance Based Pay Increases
PM-09 Sexual Harassment
PM-10A Compensation Practices and Payroll Reporting for Non-Exempt Employees
PM-10B Compensation Practices and Payroll Reporting for Exempt and Special Exempt Employees
PM-11 Employee Leaves of Absence (LOA)
PM-12 Employee Licensure Verification
PM-13 Recruitment, Hiring, Promotion and Transfer of Non-Physician Staff
PM-14 Equal Employment Opportunity and Affirmative Action
PM-15 No Solicitation and No Distribution
PM-16 Employee Travel and Reimbursement Policy
PM-16 Attachment A: Employee Travel and Reimbursement Form
PM-17 Ending the Employment Relationship
PM-18 Background Inquiries and Checks
PM-19 Pre-Employment Screening of Employees, Medical Staff, Volunteers and Contract Personnel
PM-20 Methods of Purchasing, Payment of Expenses and Return of Goods
PM-20 Appendix A: Vendor Add Request Form Process
PM-20 Appendix B: Vendor Add Request Form BIDMC Section
PM-20 Appendix C: Vendor Add Request Form Vendor Section
PM-20 Appendix D: Check Request Authorization of Payment
PM-21 Volunteer Management
PM-22 Prohibition Against Retaliation
PM-24 Discrimination and Harassment Policy
PM-25 Relationships in the Workplace
PM-26 Drug-Free Workplace
PM-27 Use of Public Space and Conference Rooms
PM-28 Trustworthiness & Reliability for Access to Certain Radiological Equipment
PM-29 Introductory Period
PM-30 Fragrance Controlled Workplace
PM-32 Compliance Exit Interview Policy
PM-34 Inclement Weather Policy
PM-35 Reasonable Accommodation of Disabled Individuals
PM-36 Massachusetts Domestic Violence Leave Act
PM-37 Earned Sick Time (EST)
PM-38 Personal Appearance

Medical Staff (MS)
MS-13 Principles Guiding Medical Education at BIDMC
MS-15 General Assignment Responsibilites of the Medical Staff for Patient Care and Clarifying Attend
MS-18 Patient Acceptance, Initial Assessment and Care Planning by the Medical Staff
MS-20 Requirements for Physician and Licensed Independent Practitioner Orders
MS-21 Documentation of the Medical History and Physical Examination Prior to a Procedure
MS-22 Service Standards for Clinical Consultation
MS-25 Documentation of the Discharge Summary
MS-26 Documentation of Inpatient Progress Notes by the Medical Staff
MS-27 Documentation of the Brief Operative Note and the Final Operative Note
MS-27A Documentation of Brief Post-Procedure Note for Procedures Performed outside of the Operating
MS-30 Monitoring the Performance of Medical Staff Members
MS-31 Radiation Risk Management for Patients Undergoing High Dose Fluoroscopy Procedures
MS-32 Clinician Health Process
MS-32 Attachment A: Clinician Health Process Flow Chart
MS-33 Approval Process for Physician to become an Authorized User for Radionuclides in the Healing A
MS-34 Review and Approval Process for New Procedures or Treatment Methods to be Performed by the Med
MS-35 Documentation of the Medical History and Physical Examination for Admitted but Non-Procedure
MS-37 Emergency Volunteer Physician Credentialing and Management Process
MS-38 Guidelines for Credentialing and Competency Assessment for Provider Performed Testing (PPT)
MS-39 Radiation Management and Safety Training Program for Physicians and Physician Assistants Oper
MS-40 Medication and Biologic Administration

Privacy (PV)
PV-01 Beth Israel Deaconess Medical Center Organized Health Care Arrangement (OHCA)
PV-04 Confidentiality
PV-05 Access, Use, and Disclosure of Protected Health Information (PHI) and Personal Information (PI
PV-06 General Agreement Form
PV-07 Safeguarding Protected Health Information and Personal Information
PV-07 Attachment A: Disposal System Grid
PV-08 Accounting of Disclosures of Protected Health Information
PV-09 Inspection and/or Copying of Medical Information
PV-10 Patient Request to Amend Protected Health Information
PV-11 Designation of Privacy Officer
PV-12 Privacy Practices for Fundraising
PV-13 Defining the Designated Record Set and the Patient Medical Record
PV-14 Mitigating the Effect of an Unauthorized Use or Disclosure of Protected Health Information wi
PV-15 Requests to Restrict Uses and Disclosures of Protected Health Information
PV-15 Appendix A: Requests to Restrict Uses and Disclosures of Protected Health Information
PV-15 Reference: Pay out of Pocket Request for Special Restrictions on Use and Disclosure of Protec
PV-16 Use and Disclosure of Protected Health Information Requiring Patient Authorization
PV-16 Appendix A: Use and Disclosure of Protected Health Information Requiring Patient Authorizatio
PV-17 Business Associates and Business Associate Agreements within the BIDMC Organized Health Care A
PV-17 Attachment A: Sample Business Associate Agreement
PV-17 Attachment B: Checklist for Determining Whether a Contractor, Vendor or Services Provider Qua
PV-19 Patient Request to Opt Out of Uses and Disclosure of Protected Health Information for Fund
PV-20 Authentication
PV-21 Limited Access to Patient Information: Patient Privacy Alert Status
PV-23 Use and Disclosure of Protected Health Information Not Requiring Patient Authorization

Research (RS)
RS-01 Medical Surveillance for High Hazard Biological and Chemical Agents Used in Research
RS-01 Appendix A: List of identified High Hazard Biological and Chemical Agents
RS-01 Appendix B: Research Medical Surveillance Assessment Form
RS-02 Investigational (Research) Agent Implementation/Management
RS-03 Billing for Investigational Procedures and Devices and Humanitarian Use Devices
RS-04 Research Deficit Policy
RS-05 Minors in Research Laboratories/Hazardous Areas
RS-06 Responding to Allegations of Research Misconduct
RS-07 Effort Reporting
RS-09 Research Space Move/Departure
RS-09 Appendix A: Laboratory Move Safety Checklist
RS-09 Appendix B: Schedule for Research Lab Move/Departures
RS-10 Research Equipment Management
RS-11 Cost Sharing
RS-13 Research Residual Funds Policy
RS-16 Cost Transfer Policy
RS-17 Use of Controlled Substances in Non-Clinical Research
RS-17 Appendix A: Standard Operating Procedures for the Use of Controlled Substances in Non-Clinica
RS-18 Research and Intellectual Property Development Policy
RS-19 Delegation of Authority for the BIDMC Committee on Clinical Investigations
RS-19 Appendix A: September 30. 2014 President & CEO’s Memo
RS-20 Investigational Device Implementation & Management
RS-20 Appendix A: Investigational Medical Device Dispensing Log
RS-21 Subrecipient Awards and Monitoring
RS-22 Research Safety Management Policy
RS-22 Appendix A: Research Safety Enforcement and Escalation Procedure
RS-24 Research Laboratory Personal Protective Equipment (PPE) Policy
RS-24 Appendix A: PPE Expectations
RS-24 Appendix B: Research Hazard Assessment Tool
RS-25 Research Cores
RS-25 Appendix 1: Purchased Service Agreements Guidelines
RS-25 Appendix 1.A.: Costing Template
RS-25 Appendix 1.B.: Revenue Tracker
RS-25 Appendix 1.C.: Billing Contract
RS-25 Appendix 1.D.: BIlling Authorization
RS-25 Appendix 1.E: Invoice for Internal Customers
RS-25 Appendix 1.F: Invoice for External Customers
RS-25 Appendix 1. G: Quote Template
RS-25 Appendix 2: Business Plan Template
RS-25 Appendix 3: Departmental Core Approval Template
RS-26 Institutional Base Salary for Sponsored Projects
RS-27 Clinical Trials Registration and Reporting Policy
RS-28 International Research Policy
RS-29 Research Data Security and Record Retention
RS-30 Phlebotomy for Research in Non-Clinical Care Areas
RS-30 Attachment A: Phlebotomy for Research in Non-Clinical Areas Training Program Checklist
RS-30 Attachment B: Emergency Protocol for Medical Complications from Phlebotomy

Information Systems (IS)
IS-01 Information Systems - BIDMC Data Network, Internet Access, and the data and information availa
IS-02 Standard BIDMC-IS Policy related Definitions and Acronyms
IS-03 Assignment of IS Security role
IS-04 Information Systems – System Access, User and Application IDs
IS-05 Terminating employee access to BIDMC computer systems and data files
IS-06 BIDMC owned computer laptops and mobile devices (personal, grant purchased, vendor, consultan
IS-07 Security Incident Response and Reporting
IS-08 Information System Activity Reviews
IS-09 Workstation Use (BIDMC Devices)
IS-10 Asset Management, Equipment and Accountability
IS-11 Workstation Physical Security
IS-12 Technical & Non-Technical Security Reviews and Assessments
IS-13 Computer Storage Media Re-usage and Disposal
IS-14 Duty to Report
IS-15 Automatic Logoff and Workstation Locking
IS-16 Logging and Monitoring
IS-17 BIDMC Data Backup and Storage Policy
IS-18 Policy Exemptions
IS-19 System Documentation
IS-20 Transmission Security and Sensitive Data Storage
IS-21 Transmission Security and Data Integrity for Remote access
IS-22 E-mail Rules
IS-23 E-mail Security
IS-24 Computer related purchases and upgrades
IS-25 Cloud Security
IS-26 Password Management
IS-27 Role Based Access
IS-28 Data Center Facility Security Policy
IS-29 Maintenance Records
IS-30 Security and Privacy Awareness and Training Policy
IS-31 Security Reminders

Clinical Guidelines (CG)
CG-01 Emergency Department Phase- Stroke Protocol
CG-02 HyperAcute Stroke (0-24 hours) Treatment Guideline/Algorithm
CG-03 Thrombolysis Protocol
CG-04 t-PA Administration and NIMU/NSICU Workflow
CG-05 t-PA Bolus & Infusion Weight-Adjusted Dosing
CG-06 NIH Stroke Scale
CG-07 Barthel Index
CG-08 Rankin Scale for Stroke Assessment
CG-12 Rehab Servcies for Stroke Inpatient Algorithm
CG-13 Stroke Patient Education/Clinical Pathway for Patients
CG-14 BIDMC Healthcare Associates HIV Manual
CG-15 Chemotherapy/Biotherapy Ordering
CP-16 Osteoporosis Pharmacotherapy Guidelines
CG-17 Guidelines for initiating an Inpatient Code ST segment elevation myocardial infarction (STEMI
CG-18 Invasive Cardiology Rapid Response
CG-19 Digestive Disease Center / West Procedures Center Rapid Response
CG-20 Dermatology Surgery Rapid Response
CG-21 Arnold Pain Management Center Rapid Response
CG-22 Radiology Rapid Response
CG-23 Guidelines for the Use of the MOLST Form
CG-24 Massive Hemorrhage Transfusion Protocol
CG-25 Guidelines For Service Animals In Patient Care Areas
CG-26 Guideline for the Management of Actual or Suspected Patient Elopement
CG-27 Patient Generated Health Data
CG-28 Guidelines for Interdisciplinary Comfort-Focused End-of-Life Care
CG-29 Interdisciplinary Indwelling Urinary Catheter Guideline
CG-29 Attachment A: Difficult Foley Insertion Algorithm
CG-29 Attachment B: Examples of Indwelling Urinary Catheter Guidelines
CG-29 Attachment C: Post-Indwelling Urinary Catheter Removal Algorithm
CG-29 Attachment D: Q&A: Post-Indwelling Urinary Catheter Removal Algorithm
CG-30 Insertion of peripheral intravenous access and initiation of intravenous fluids as a Standing

Transitioning from Inpatient Acute Care to Inpatient Hospice Care at BIDMC
Multidisciplinary Guideline for Management of the Inpatient Hospice Patient Encounter at BIDMC