Policy and Procedure Manual

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Columbia University Health Care Manual of Health Information Policies

Introduction to the Manual of Clinical Policies:

Clinical Policies and Procedures are reviewed annually, updated as needed, and approved by the Clinical Policy Committee and then by the Clinical Care Committee. The Manual of Clinical Policies is divided into four (4) sections. Each section is listed below with a short description of its contents. By selecting any of the sections you will reach their complete table of contents.

Policies and Procedures General Operations: The General Operating polices include policy and procedures on those items involved in normal operations. Included, but not limited to, would be: Hours of operation, patient bill or rights, registration procedures, fee structure and schedules, payment issues, third party insurance, clinic maintenance, quality assurance, patient complaints and internal prescription programs.

Policies and Procedures Environmental Health and Safety: The Environmental Health and Safety policies would include, but not be limited to policy and procedures on those items involved in infection control, asepsis, sterilization, safety, safe use and disposal of materials, and dress codes.

Policies and Procedures Health Information: The Health Information policies include, policy and procedures on all items pertaining to Patient Records. This includes but is not limited to: copies of records, confidentiality issues, distribution and others.

Policies and Procedures on the use of ionizing radiation: Polices on the use of ionizing radiation include procedures on prescription of radiographs, facility compliance, and implications to the patient.

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Columbia University Health Care Manual of Health Information Policies

Contents – Operating Policy Manual
Registration and Triage ................................................................................................................... 5 Patient Triage .................................................................................................................................. 7 Fee Schedule.................................................................................................................................... 9 Patients' Bill of Rights and Responsibilities ................................................................................... 11 Patient Payments .......................................................................................................................... 13 Patient refunds .............................................................................................................................. 14 Processing of third party insurance forms .................................................................................... 15 Operatory maintenance ................................................................................................................ 17 Operatory repair requisition. ........................................................................................................ 18 Obtainment of Clinic Supplies ....................................................................................................... 19 Sending Cases to Outside Laboratories for Processing ................................................................. 21 Processing remakes at outside laboratory .................................................................................... 23 Lost or Stolen Instrument Replacement ....................................................................................... 24 Removal of Hard and Soft Tissue................................................................................................... 26 Transfer of patients between providers........................................................................................ 28 Quality Assurance/Performance Improvement Plan .................................................................... 29 Patient Complaints ........................................................................................................................ 31 Provision for communicating with patients with communication barriers ................................. 32 Identifying Possible Victims of Abuse ................................................................................... 33 Referral for non-available services ................................................................................................ 34 Medical Emergencies..................................................................................................................... 35 Location of Medical Emergency Equipment. ........................................................................ 36 Dental Emergencies ....................................................................................................................... 38 Availability of Policies and Procedures, Exposure Control Plan, and MSDS sheets ...................... 40 CPR Certification ............................................................................................................................ 41 Invisalign Protocol ......................................................................................................................... 42 Antibiotic Prophylaxis for reducing the risk of Infective Endocarditis (IE) .................................... 44 New York State Prescription Program ........................................................................................... 47 Internal Prescription Program at Columbia University College of Dental Medicine ..................... 48

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Columbia University Health Care Manual of Health Information Policies

Infection Control............................................................................................................................ 50 Recall of Sterilized Instruments ..................................................................................................... 51 Instrument Processing ................................................................................................................... 52 Instrument Requests and Returns................................................................................................. 54 Dress Code for Clinical Care .......................................................................................................... 55 Professional dress code for students, faculty and staff ................................................................ 57 Waste disposal............................................................................................................................... 58 Incident Reports ............................................................................................................................ 59 Receipt, Cleaning, Decontamination, Disinfection of Reusable Items .......................................... 61 Assembly, Wrapping and Instrument Sterilization........................................................................ 63 Autoclave Loading ......................................................................................................................... 66 Cleaning Procedures for Sterilizers ............................................................................................... 67 Sterilizer Failure Recall .................................................................................................................. 68 Dress Code for Instrument Processing .......................................................................................... 69 Biological Monitoring: Spore Testing ........................................................................................... 71 Sterilization Indicators ................................................................................................................... 72 Bowie & Dick Test Pack ................................................................................................................. 73 Disposal of extracted teeth (REFERNCE/attach Amalgam Algorithm) .......................................... 75 6. Amalgam Disposal (REFERNCE/attach Amalgm Algorithm) ................................................. 77

Collection of non-contact amalgam scrap and capsules ............................................................... 78 The Collection and Disposal of Lead Foil ....................................................................................... 79 Removal of Radiographic Fixer Solution from self-contained processors .................................... 80 Collection radiographic film .......................................................................................................... 81 Use of Sodium Hypochlorite as an Irrigation Solution .................................................................. 82 Hand Hygiene ................................................................................................................................ 83 Use of Nitrous Oxide ..................................................................................................................... 85 Access To Patient Information ...................................................................................................... 90 Purging inactive patient records ................................................................................................. 102 Introduction --Patient Records Department ............................................................................... 104 Objectives of the Patient Records Department .......................................................................... 107 Use of Patient Records ................................................................................................................ 109 Safeguards of Records and Computerized Data from Damage, Loss or Tampering. .................. 111

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Color Coding of Patient Record Folders ...................................................................................... 114 Arrangement of Patient Record .................................................................................................. 115 Retrieval of Patient Records ........................................................................................................ 118 Filing of Loose Forms ................................................................................................................... 120 Disposal of Confidential Documents ........................................................................................... 121 Dental Record Room Employee Training/Orientation ................................................................ 122 Subpoenaed Patient Records ...................................................................................................... 123 Confidentiality of Patient Records / Patient Information and Guidelines for the Release of Information.................................................................................................................................. 128 Schedule of Fees for Processing Request for Patient Information.............................................. 140 Patient Record Requisition. ......................................................................................................... 142 Confidentiality of Patient Records Containing HIV-Related Information .................................... 146 Dental Record Completion .......................................................................................................... 152 Filing of Patient Records. ............................................................................................................. 153 Health Information Forms ........................................................................................................... 155 Informed Consent........................................................................................................................ 156 Medical Alert Stickers .................................................................................................................. 158 Dental Record Duplication .......................................................................................................... 159 Facsimile of Patient Information ................................................................................................. 160 Radiology Prescription Form ............................................................. Error! Bookmark not defined. Radiology Facility Compliance ........................................................... Error! Bookmark not defined. Institutional Obligations to the Patient ............................................. Error! Bookmark not defined.

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Columbia University Health Care Manual of Health Information Policies

Registration and Triage
POLICY: All patients treated at Columbia University College of Dental Medicine must be registered.

PURPOSE:

To insure that all patients have a record of treatment and an informed consent for that treatment.

PROCEDURE:

1.

The hours of registration for new patients are 8:30-12:00 M-F 1 - 3 PM M-F. Patients do not sign in, are registered first come first serve by privately completing registration material and then privately reviewing it with a registrar.

2.

At the time of registration the patient must complete a

a. b. c. d.

General Consent Health history form Demographics form for registration HIPPA Privacy Statement

3.

Registration fee must be paid.

4.

A chart is assembled for registered patients. This chart includes at minimum:

a.

A health history form with consent

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b. c. c. d. e.

Informed Consent A HIPPA statement Examination and charting sheet Radiology envelope Continuation sheet

5.

All patients must be registered prior to treatment.

6.

All patients under the age 12 are referred directly to Pediatric Dentistry for their registration.

7.

All patients with a direct referral note from their private dentist must be registered but then can go directly to the specifically requested specialty clinic. If they do not have a referral slip they must be registered and triaged to the appropriate provider.

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Patient Triage
POLICY: All newly registered patients without a referral will be examined and triaged.

PURPOSE:

To screen all new patients, evaluate their dental needs and refer them to the appropriate care provider.

PROCEDURE:

1.

All new patients upon completion of their registration are brought to the clinical area for a rapid evaluation and triage. The registration data is examined for completeness. This includes appropriate patient signatures and chart entries. The consent form must be reviewed for signature. The medical history is reviewed. Additional questions for completeness are asked. The history should be countersigned by the examiner. Vital signs of blood pressure and pulse are obtained. A peri-oral and intra-oral examination is completed making appropriate notes. A prescription for radiographs is documented in the chart, with a radiology prescription and ordered. Once radiographs are completed the patient is assigned to the most appropriate primary care area for comprehensive treatment. Patients requesting a provider must have approval from a program director or clinic administration The patient is brought to that area for a comprehensive treatment planning appointment to be made with a primary care provider. Patient must be assigned to a primary provider and computer entry made. Every attempt should be made for the patient to leave with an appointment for comprehensive treatment planning. This appointment should be as soon as possible.

2.

3. 4.

5. 6. 7.

8.

9.

10.

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11.

Patients referred to the School from a provider specifically for specialty care should be referred directly to that clinic once registered.

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Fee Schedule
POLICY: The fee schedule maintained at the College of Dental Medicine should be reviewed annually. Self Pay fees must be equal to or greater than those of the State Medicaid program.

PURPOSE:

The review is intended to adjust fees on a scheduled basis.

PROCEDURE:

1. 2. 3. 4. 5.

Each April the present fee schedule will be circulated to the Clinical Policy Committee. Corrections/deletions will be made. These changes will be reviewed by clinic administration. The revised schedule will be returned for final approval. July 1 the new schedule will come into effect. All new patients will be charged at the new fee schedule rate. In the event that fees need to be changed at other times of the year they must submitted to clinic administration for approval. All self pay fees must be equal to or greater than Medicaid procedure fees at all times. Persons over the age of 65 are entitled to a 10% fee reduction as senior citizens. This fee is rounded to the next highest dollar Undergraduate Columbia University students with a current identification card who are enrolled in the student health plan are entitled to a 10% fee reduction rounded to the next highest dollar. Students not enrolled are charged regular clinic fees. Immediate family of College of Dental Medicine (CDM) predoctoral and postdoctoral students tuition paying (parents, grandparents, spouses, and siblings) are entitled to a 100% fee reduction when treated by the family member and no reduction when treated by another provider. Lab fees must be covered separately.

6.

7. 8.

9.

10.

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11.

CDM students are entitled to a 75% fee reduction rounded to the next highest dollar when treated by a postdoctoral student and 100% if treated by a predoctoral student. This does not apply to Invisalign Orthodontic or surgical implant placement cases. The fee must cover the lab fee if not it will be raised to that fee. Approval of educational discounts must be in writing by the program director in the patient’s record. Implant fee’s will only be reduced for greater than 3 implants and must be approved by the program director surgically placing the implants.

12.

13.

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Patients' Bill of Rights and Responsibilities
POLICY: All patients shall be treated adhering to the patients’ bill of rights as outlined below. These will be posted on each floor of the Dental Clinic, and a copy given to each patient when they register.

PURPOSE:

To ensure that all patients are treated in the appropriate manner.

PROCEDURE: Patients have a right to and responsibility for:

1. Understanding these rights. If necessary we will supply assistance and an interpreter.

2. Receiving treatment without discrimination as to color, religion, sexual orientation, disability or source of payment.

3. Receiving considerate and respectful care in a clean and safe environment.

4. Receiving emergency care if needed.

5. Being informed of the name and position of the persons rendering care and names and position of administrative staff.

6. Receiving complete information about their dental diagnosis, treatment, and prognosis.

7. Receiving all the information needed for them to give informed consent including

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possible risks and benefits.

8. Refusing treatment and be told of the possible consequences.

9. After a full explanation, they have a right to refuse to take part in research.

10. Privacy and confidentiality of all information regarding their care.

11. Participate in decisions regarding their care.

12. Obtain their dental record for which they may be charged a reasonable fee. They cannot be denied a copy solely because of inability to pay.

13. Receiving a receipt for and explanation of all charges.

14. Complaining without fear of reprisals. If a patient is not satisfied, they may address their concerns to the section administrator of their area of care, the faculty program director or the Patient Ombudsman. If they are still not satisfied, they may call the Office of Clinic Administration to schedule an appointment with the Clinical Dean.

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Columbia University Health Care Manual of Health Information Policies

Patient Payments
POLICY: All patients are required to pay at the time of the procedures.

PURPOSE:

To maintain the smallest possible accounts receivable and minimize billing.

PROCEDURE:

1.

All patients must register PRIOR to being seated for care.

2.

All patients will be asked to make a payment toward the procedure that is being performed in accordance with the current fee schedule.

3.

The patient payment will be credited to their account and logged into the Clinic Information system according to location and provider.

4.

Patient payments must be up to date.

5.

A minimum of 50% must be paid toward any prosthetic care before it will be permitted to be sent to the laboratory.

6.

Full payment is required prior to final insertion.

7.

The patient will be given a receipt for their payment. This receipt is part of the computer generated invoice.

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Columbia University Health Care Manual of Health Information Policies

Patient refunds
POLICY: All patient refunds must be approved by the Program Director effected, the program administrator and the Director of Clinical Business Affairs or Director of Clinical Operations.

PURPOSE:

To provide a mechanism for patient refunds and tracking of such refunds.

PROCEDURE:

1.

The need for a refund should be brought to the attention of the program administrator by the faculty and student responsible for the total treatment plan.

2.

The program administrator informs the Program Director.

3.

The Program Director will then decide on the appropriateness of the refund, document in the chart and inform the Director of the Clinic Business Office.

4.

Clinic Administration will then process the refund.

5.

The patient should be informed that the refund usually takes about 6 weeks.

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Processing of third party insurance forms
POLICY: All third party insurance plans will NOT be accepted as payment. Insurance forms will only be completed when patients are paid in full with payment sent directly to the patient.

PURPOSE:

To complete insurance forms

PROCEDURE:

A)

Quick claim

1) 2) . B) . 1)

At the time of each payment an insurance receipt should be printed. This insurance receipt must be signed with a faculty signature

Carriers that will not accept a quick claim and or require a hand signature

Forms that are being submitted to the business office should be accompanied by the patient chart and an insurance routing form. The insurance form must be completed by the business office and signed by the patient. The patient's account balance must be ZERO before the completed form is mailed. Prior to sending the form it must be duplicated for the business office records.

2)

3)

4)

PRE-ESTIMATE:

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C) 1) The insurance form must be completed by the student and signed by the patient. Prior to sending the form, it must be reviewed by the business office and a copy will be kept on file.

2)

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Columbia University Health Care Manual of Health Information Policies

Operatory maintenance
POLICY: Operatory maintenance is the responsibility of the student who is using the operatory.

PURPOSE:

To maintain the cleanliness and integrity of the unit.

PROCEDURE:

1.

At the beginning of each clinic session the student will clean the operatory using an appropriate disinfectant as outlined in the Infection Control Manual.

2.

Cover the chair and counter space with appropriate barriers.

3.

Light handles, switches, and tubing will be covered with appropriate barriers.

4.

At the end of the session the student will remove the barriers and disinfect the operatory appropriately.

5.

At the end of the day the chair should be placed in the most upright position and all disposables should be removed and placed in the appropriate receptacles.

6.

Units with self contained water units must be maintained as outline in the Section on Environmental Health and Safety.

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Columbia University Health Care Manual of Health Information Policies

Operatory repair requisition.
POLICY: Operatory repair requests should be made through the office of clinic administration.

PURPOSE:

To maintain the functioning of all operatory equipment and to repair such equipment on a timely basis.

PROCEDURE:

1.

A malfunction of operatory equipment should be reported to clinic administration.

2.

The request should be placed in writing.

3.

A request for service must be filled out in the repair book (VC-8 Module Supply).

4.

The date of request should be noted.

5.

Failure of clinic administration to respond to this request should be brought to the attention of the administrator.

6.

Emergency requests should be done through the page system by contacting the module staff.

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Columbia University Health Care Manual of Health Information Policies

Obtainment of Clinic Supplies
POLICY: Obtainment of Clinical Supplies should be made by the Office of Clinic Administration through the Program Administrator.

PURPOSE:

To provide clinic supplies in a timely manner and to track the use of supplies through each program.

PROCEDURE:

1.

Each supply module must maintain an inventory of supplies.

2.

This inventory should be developed with markers for reordering in a timely manner.

3.

A request for supplies should be sent to the program administrator.

4.

The requisition should be turned into clinic administration.

5.

Items of special order should be requested through clinic administration. This request must include justification.

6.

Failure to order as described in this policy will result in undue delays.

7.

Module supply dispensary areas should maintain no more than a 10 day supply of any item.

8.

Capital requests are made annually for those items of value greater than $2,500 and a

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life expectancy of at least 3 years.

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Columbia University Health Care Manual of Health Information Policies

Sending Cases to Outside Laboratories for Processing
POLICY: Cases will ONLY be sent to DESIGNATED outside laboratories using the following procedure.

PURPOSE:

To control the laboratories used and the process in using them.

PROCEDURE:

1.

Cases MUST only be sent to approved laboratories. Always continue with the same laboratory.

2.

The prescription must be completed on line, saved, and printed. The printed copy is signed by the student, a faculty member and the case submitted for authorization.

3.

Authorization stamps on the prescription are obtained from the Module staff and can only be obtained if 50% of the fee has been received. A note is posted in the Clinic Information System when approved.

4.

Cases are to be left in the designated areas on VC-7, VC-8, and VC-9.

5.

Cases are brought by administration to be processed centrally.

6.

Cases are logged in and given an authorization tracking number only if the cases is noted in the Clinic Information System, has been logged in to the prescription web site, has an authorization stamp and a faculty signed prescription.

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7.

Rejected cases are so noted with an email to the provider.

8.

Returned cases are logged in by invoice number, the prescription is copied, filed and the provider is emailed that the case has returned.

9.

Lab cases are picked up by the provider. A university ID and signature is required.

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Columbia University Health Care Manual of Health Information Policies

Processing remakes at outside laboratory

POLICY:

All remakes will be sent back to the same processing laboratory.

PURPOSE:

To prevent double charge for laboratory error.

PROCEDURE:

1. Prepare the case for processing in the normal fashion as described in the policy “Sending Cases to Outside Laboratories for Processing”.

2. The redo section must be checked on the prescription..

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Lost or Stolen Instrument Replacement
POLICY: All lost or stolen instruments must be reported to the Office of Clinic Administration

PURPOSE:

To insure reporting and replacing instruments

PROCEDURE:

1. All lost or stolen instruments must be reported to the Office of Clinic Administration within 7 days of this recognition by the completion of an “Instrument Loss Claim Form”. This form can be obtained from PH-7-Stem 126

2. The report will be reviewed by the Office of Clinic Administration within 7 days of submission

3. If a physical break in or an observed theft is reported, the student must report to security immediately and then to Clinic Administration to complete an “Instrument Loss Claim Form”.

4. If instruments were lost in sterilization, student must have a completed “Instrument Request Form” to have them replaced.

5. Student is informed of committee decision within 14 days of claim.

6. The Office of Clinic Administration will recommend replacement on first offense as follows:

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Columbia University Health Care Manual of Health Information Policies

Instruments lost by direct accountable theft will be replaced at 100% instrument value. Instruments lost due to proven mishandling of instruments during processing will be replaced at 100% instrument value Instruments lost due to carelessness will be replaced at 50% instrument value or less.

Students must complete an Instrument Replacement Form to have instruments replaced.

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Columbia University Health Care Manual of Health Information Policies

Removal of Hard and Soft Tissue
POLICY: All hard and soft tissue removed in any clinic must be examined grossly by the attending faculty member and possibly by microscopy in oral pathology.

PURPOSE:

To ensure all specimens are handled in an appropriate manner.

PROCEDURE:

1.

All removed hard and soft tissue must be examined grossly by the attending faculty member.

2.

Extracted teeth and infected periodontal tissue that is removed must be grossly examined by clinical Faculty.

3.

When microscopic examination is indicated, a specimen bottle and oral pathology submission requisition must be obtained from the supply module and completed.

4.

All intraoral and perioral hard and soft tissue to be examined microscopically must be examined by an attending doctor and timely placed into 10%formalin fixation.

5.

All billing data: including Medicare, Medicaid, private patient information is to be completed on the biopsy requisition form prior to submission to Oral Pathology.

6.

All specimens are to be submitted to the Oral Pathology Laboratory, PH 15 W 1562.

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Columbia University Health Care Manual of Health Information Policies

7.

Oral Pathology personnel will perform gross and microscopic examination of all hard and soft tissue specimens submitted.

a.

Not all hard tissues submitted will be further processed microscopically, e.g. teeth may simply undergo gross examination with report.

b.

All soft tissues will be processed and stained in hematoxylin and eosin routinely, when necessary - additional special stains will be utilized.

8.

All reports will be issued by Oral Pathology, sent to clinic administration and filed in the patient’s record and the provider notified

9.

If oral pathologic examination is required, the patient must be informed that a separate fee is charged for the oral pathology (0501).

10.

All findings must be recorded in the patients chart.

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Transfer of patients between providers
POLICY: Patients in need of a new provider are transferred for continued care

PURPOSE:

To ensure transfer of patients to appropriate providers

PROCEDURE:

1. No patient may be transferred more than once from one pre-doctoral candidate to another.

2. Any case under the care of a pre-doctoral candidate not completed after one transfer must be assigned to a higher lever provider.

3. These cases must be considered carefully by the program director.

4. A list of these cases must be maintained by the program director and forwarded to the Associate Dean for Clinical Affairs.

5. Higher level providers include Postgraduate General Dentists (AEGD, GPR) or Postgraduate Prosthodontics and Faculty.

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Columbia University Health Care Manual of Health Information Policies

Quality Assurance/Performance Improvement Plan
POLICY: A quality assurance program, based on standards of care, outcome measures, and to monitor and improve patient care must exist.

PURPOSE: To enhance the outcomes of patient care through a planned quality improvement program based on established standards to measure the quality of patient care. To identify opportunities for performance improvement and to review policies and procedures at least annually and revise as necessary.

PROCEDURE:

1. The Chairperson of the Health Care Evaluation, Quality Assurance and Performance Improvement Committee supervises the quality assurance program.

2. The Committee establishes criteria for standards of professional practice, for monitoring and assessing patient care and clinical performance, which are updated as needed.

3. The Quality Assurance Program includes regularly scheduled review of patient records, patient complaints and suggestions, reported incidents and any other documents pertinent to problem identification.

4. The Health Care Evaluation, Quality Assurance and Performance Improvement Committee, which includes representation from all programs meets monthly.

5. All Quality Assurance documents and reports are considered confidential.

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6. All policies and procedures and standards of care are reviewed at least annually and revised as necessary. The Clinical Care Committee will approve, sign and date all policies and procedures.

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Columbia University Health Care Manual of Health Information Policies

Patient Complaints
POLICY: The Clinics have mechanisms in place for patients to register complaints.

PURPOSE:

To allow patients to lodge complaints without fear of repercussion.

PROCEDURE: 1. A suggestion/complaint box is located within each clinical area. 2. Suggestion/complaint cards are available for anonymous use. 3. Patients are provided with address, telephone and email access to lodge complaints. 4. A patient ombudsman is available for all patients. 5. Patients or visitors with complaints are referred to the Patient Ombudsman. 6. Complaints and responses are documented in writing. 7. A log of complaints must be maintained along with resolutions

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Provision for communicating with patients with communication barriers
POLICY: Patients with special communication needs will be assisted to facilitate effective communication.

PURPOSE:

To ensure that patients with special needs are identified and receive prompt and expedient care.

PROCEDURE:

1. Patients with special needs will be identified on initial visit. These patients may be blind, non-English speaking, or physically (wheelchair, cane, walker, etc.) challenged.

2. For patients who speak a language other than English, a translator if needed will be provided. Educational material will be available in English and Spanish.

3. For patients who are blind, all efforts will be made to obtain forms in Braille, if the patient can “read Braille”. As an alternative, a staff member may read all necessary forms to the patient, and assist in writing responses if necessary.

4. For hearing impaired patients, a sign language interpreter if needed will be obtained to assist the patient during their visit.

5. For physically challenged patients needing assistance, the staff will expedite any needed special accommodations.

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Columbia University Health Care Manual of Health Information Policies

Identifying Possible Victims of Abuse

POLICY:

All staff shall assess and report suspected cases of child abuse, neglect or maltreatment. Clinicians will assess patients in their care for possible sexual, elder or domestic abuse.

PURPOSE:

To outline criteria to be used in assessing patients for possible abuse and to outline the procedure to follow if abuse is suspected or confirmed.

PROCEDURE:

1. Determination of actual or suspected child abuse, neglect or maltreatment: Faculty and staff to be trained in recognition of family indicators, physical abuse/behavioral indicators, and sexual abuse criteria.

2. Determination of actual or suspected elder abuse, neglect or maltreatment: Faculty and staff to be trained in recognition of physical abuse, emotional abuse and financial abuse criteria.

3. Determination of actual or suspected domestic violence: Faculty and staff to be trained in recognition of physical abuse, verbal abuse, violent behavior and emotional abuse criteria.

4. A staff member who believes that a patient might be a victim of abuse according to the above criteria will contact the Office of Social Services in the New York Presbyterian Hospital. The social worker will follow the established policies and procedures of the Social Work Department.

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Columbia University Health Care Manual of Health Information Policies

Referral for non-available services
POLICY: Patients will be referred for services not provided at the College of Dental Medicine.

PURPOSE:

To refer patients to providers for needed services not provided at the College of Dental Medicine.

PROCEDURE:

1. All patients are evaluated for health care needs.

2. Patients in need of services not provided will be referred to appropriate facilities

3. Patients with medical needs will be referred to their primary care provider or the AIM (Associates in Internal Medicine) clinic of New York Presbyterian Hospital.

4. Patients with Oral Health Care needs beyond the scope of the facility will be provided with clinic referrals or faculty practice.

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Columbia University Health Care Manual of Health Information Policies

Medical Emergencies
POLICY: In the event of a medical emergency the protocol outlined in the Manual on Emergency Response will be followed.

PURPOSE:

To have in place a plan to respond to Medical Emergencies.

PROCEDURE:

1.

In the event of a Medical Emergency the treating provider must assess the patient and take appropriate action.

2.

The provider must call for HELP.

3.

The HELP must summon the Attending Faculty member to the area and then obtain Oxygen and Sphygmomanometer.

4.

The Emergency Response Team will be summoned if needed by the Attending Faculty member.

5.

The disposition of the patient will be determined and treatment rendered following the guidelines in the Manual on Emergency Response.

6.

Practice scenarios will be done on a scheduled basis.

7.

Emergency phone numbers will be posted on all phones.

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Columbia University Health Care Manual of Health Information Policies

Location of Medical Emergency Equipment.

POLICY:

All Medical Emergency Equipment will be located in designated areas.

PURPOSE:

To maintain emergency medical equipment in accessible areas, fully stocked and available to respond to medical emergencies.

PROCEDURE:

1.

Crash cart medical supplies will be maintained by the Pharmacy of New York Presbyterian Hospital.

2.

Contents of each cart conform to that of New York Presbyterian Hospital.

3.

Crash carts and AED’s (Automated External Defibrillators) are located on VC-7 in Oral Radiology corridor, VC-8 in AEGD area and VC-9 in the alcove at the front of the general clinic.

4.

A defibrillator is also located with the VC-7 Oral and Maxillofacial surgery clinic and is continuously charged.

5.

Crash Carts are checked and documented for lock integrity daily.

6.

Each Crash Cart must contain Oxygen and a Sphygnomanometer.

7.

Each emergency location also maintains supplemental oxygen.

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8.

The Nurse Manager and the Assistant Director of Clinical Operations is responsible for maintaining the emergency medical equipment protocol.

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Columbia University Health Care Manual of Health Information Policies

Dental Emergencies
POLICY: Patients with dental emergencies will have access to care 24 hours a day 7 days per week.

PURPOSE:

To render emergency dental care.

PROCEDURE:

1.

Active dental patients with dental emergencies will initially try and contact their provider.

2.

Active dental patients unable to contact their provider will be seen in the triage registration area on VC-7 from 8:30 am to 3:30 pm Monday through Friday.

3.

Active dental patients after 3:30 pm Monday through Friday who are unable to contact their provider will be seen in the emergency room of New York Presbyterian Hospital by a dental resident.

4.

Dental Residents are assigned by an on-call schedule with an Attending.

5.

In-active Emergency patients without a provider will be seen in the triage registration area on VC-7 from 8:30 am to 3:30 pm Monday through Friday.

6.

In-active Emergency patients after 3:30 pm Monday through Friday who are unable to contact their provider will be seen in the emergency room of New York Presbyterian Hospital by a dental resident.

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7.

Dental Residents are assigned by an on-call schedule with an Attending.

8.

Emergency coverage for all College of Dental Medicine patients is available on Holidays and weekends in the emergency department of New York Presbyterian Hospital.

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Columbia University Health Care Manual of Health Information Policies

Availability of Policies and Procedures, Exposure Control Plan, and MSDS sheets
POLICY: All Faculty, Students and Staff must have access to the Operational Policies and Procedures, the Exposure Control Plan, and Manufacture Safety Data Sheets (MSDS).

PURPOSE:

To allow Faculty, Students and Staff access to needed information.

PROCEDURE:

A copy of the Policy and Procedure manual containing sections on Operational Policies, Environmental Health and Safety, Ionizing Radiation and Health Information is available in the Office of Clinic Administration, on the Web, and on CD-ROM.

A copy of the Exposure Control Plan is available in the Office of Clinic Administration, on the Web, and on CD-ROM.

MSDS are available on VC-8 in Central Sterilization and in the Office of Clinic Administration.

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CPR Certification
POLICY: All Clinical Faculty, Students and Staff must be, if physically able, certified in Basic Cardiac Life Support (CPR).

PURPOSE:

To ensure the ability to recognize and respond in an appropriate manner to medical emergencies.

PROCEDURE:

1. All pre-doctoral and postdoctoral students will be required to take a certification course in Basic Cardiac Life Support.

2. Pre-doctoral students will be enrolled in the course on dental emergencies prior to entering the clinic.

3. Postdoctoral students will be enrolled in a certification course during their orientation and two years after for programs lasting for more than three years.

4. Clinical faculty will be offered CPR training through continuing education programs throughout the year.

5. Clinical Support Staff will be provided training twice per year.

6. Records will be maintained in the Office of Clinic Administration

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Invisalign Protocol
POLICY: All Clinical Faculty, Students and Staff must, follow Invisalign Protocol in providing these Orthodontic services to patients.

PURPOSE:

To ensure the appropriate patient care, tracking and payment.

PROCEDURE:

1. Identification of case by student. 2. Consult with generalist faculty who are Invisalign Certified a. Dr. Odusola b. Dr. Mirsky c. Dr. Bruzzi d. Dr. Terman e. Dr. Freeman 3. Diagnostics a. Study Models, FMS and Panoramic Film 4. Consult with all Diagnostics with identified Orthodontic Faculty a. Dr. Winslow b. Dr. Santoro c. Available 9th Floor Orthodontic Faculty 5. Consult with Patient a. Consent i. Possible treatment needed with appliances and additional fees after completion with the invisalign stents.

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ii. Required patient, faculty and student signatures. b. Fees i. $2700 for clinic patients 1. $900 down 2. $1,800 on contract for $300 per month ii. $1000 for CDM students c. Cephlometric film if reqired i. Taken by appointment with in Orthodontics ii. $100 transfer to Orthodontics iii. Cephlometric film to be traced by student d. Photos i. 8 photos 6. Submit Completed information to VC-7 Biller: Ms. Patricia Deeble and to be logged into Clinic Business Office data base by completion of an online prescription. 7. Submission to Invisalign 8. Case return to Clinic Business Office, logged in and then distributed to the student. 9. Treatment.

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Antibiotic Prophylaxis for reducing the risk of Infective Endocarditis (IE)
Policy: of IE. To define the appropriate times for prescribing antibiotics for reducing the risk

Purpose:

To appropriately prescribe antibiotics to reduce the risk of IE.

Procedure: Antibiotic prophylaxis is required for certain patients to reduce the risk of Infective Endocarditis.

1.

Every patient must have a complete medical history taken at the time of registration and have it updated at appropriate intervals. The American Heart Association guidelines of April 2007 are required to be followed for patients with the following conditions (as described by the American Dental Association) who are at greatest risk in developing IE. These include patients with: A. Artificial heart valves B. A history of infective endocarditis C. Certain specific, serious congenital (present from birth) heart conditions, including o unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits o a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure o any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device D. A cardiac transplant that develops a problem in a heart valve.

2.

3.

The following are the recommended antibiotic regimens for such patients as listed above.

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4. Patients that previously required antibiotics are listed below but no longer require antibiotic prophylaxis. These patients include those with: mitral valve prolapse (with or without regurgitation) rheumatic heart disease bicuspid valve disease calcified aortic stenosis congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy.

5. Only those patients at the greatest risk of developing IE after a bacterimia are recommended to have antibiotic prophylaxis for the following procedures: All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. This includes: Routine restorative dental care. Root planning, scaling and Prophylaxis

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Columbia University Health Care Manual of Health Information Policies

Fixed prosthodontics Preparation of teeth Any surgical procedure Taking of impressions

6. The following procedures and events do not need prophylaxis even for patients at greatest risk: Routine anesthetic injections through non-infected tissue. Taking dental radiographs. Placement of removable prosthodontic or orthodontic appliances. Placement of orthodontic brackets. Natural loss of primary teeth Bleeding from natural trauma to the lips or oral mucosa.

7. In cases of uncertainty consultation with the patients physician is recommended.

These guidelines were adapted from the ADA and are available through the ADA at:

http://www.ada.org/prof/resources/topics/infective_endocarditis.asp

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New York State Prescription Program
Policy: To minimize potential abuse of prescriptions and medications.

Purpose:

To maintain a system to distribute prescriptions appropriately.

Procedure: The following practices will be observed when writing prescriptions for medications to be obtained at outside pharmacies:

1.

All prescriptions written in the State of New York, as of April 19, 2006 MUST be written on official New York State prescription pads. CUHC maintains a supply of official New York State prescription pads. The prescriptions CANNOT be copied and only originals will be accepted at pharmacies. The licensed CUHC appointed provider MUST stamp (on the upper right of the prescription) and sign the prescription at the bottom. If applicable the institution’s DEA number must be filled in on the upper left of the prescription. BC8011695. Each prescription is bar coded and is tracked by the New York State Health Bureau of Narcotic Enforcement. A note reflecting the writing of a prescription MUST be included in the patient’s health record and include the drug ordered, the amount ordered, the instructions for taking the medication and the number of refills. 2 Prescription pads will be maintained in each of the following areas: VC-7 and VC-8 supply modules, Oral and Maxillofacial Surgery Clinic, Implant Suite, Postdoctoral Endodontics and Postdoctoral Periodontics. Replenishment of prescriptions must be done through the Office of Clinic Administration. Prescription pads MUST only be used for the writing of prescriptions and NOT for scrap paper, patient instructions, and/or notes for patients.

2. 3.

4.

5.

6.

7.

8.

9.

10.

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Internal Prescription Program at Columbia University College of Dental Medicine
Policy: To appropriately track the writing of internal prescriptions and medications.

Purpose:

To maintain a system to distribute prescription medications maintained at CDM.

Procedure: The following practices will be observed when writing prescriptions for medications to be obtained internally:

1.

All internal prescriptions MUST be written on a Columbia University College of Dental Medicine prescription. CDM prescriptions can be printed from the CDM intranet by going to the Clinical portion of the intranet, Clinical Resources, Clinic/Patient Forms and finally CDM Prescription. A licensed CUHC appointed provider MUST stamp and sign the prescription at the bottom. A note reflecting the writing of a prescription MUST be included in the patient’s health record and include the drug ordered, the amount ordered, the instructions for taking the medication and the number of refills. The written prescription must be brought to Oral and Maxillofacial Surgery or the implant suite where the medication will be dispensed and the prescription maintained on file.

2.

3.

4.

5.

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Contents - Manual of Environmental Health and Safety
Infection Control ................................................................................................. 50 Recall of Sterilized Instruments ........................................................................... 51 Instrument Processing......................................................................................... 52 Instrument Requests and Returns....................................................................... 54 Professional dress code for students, faculty and staff. ..................................... 57 Waste disposal .................................................................................................... 58 Incident Reports .................................................................................................. 59 Receipt, Cleaning, Decontamination, Disinfection of Reusable Items. ............... 61 Assembly, Wrapping and Instrument Sterilization.............................................. 63 Autoclave Loading ............................................................................................... 66 Cleaning Procedures for Sterilizers ..................................................................... 67 Sterilizer Failure Recall ........................................................................................ 68 Dress Code for Instrument Processing ................................................................ 69 Biological Monitoring: Spore Testing ................................................................. 71 Sterilization Indicators......................................................................................... 72 Bowie & Dick Test Pack ....................................................................................... 73 Disposal of extracted teeth (REFERNCE/attach Amalgam Algorithm) ................ 75 Amalgam Disposal (REFERNCE/attach Amalgm Algorithm) ................................ 77 Collection of non-contact amalgam scrap and capsules ..................................... 78 The Collection and Disposal of Lead Foil. ............................................................ 79 Removal of Radiographic Fixer Solution. ............................................................ 80 Collection radiographic film. ............................................................................... 81 Use of Sodium Hypochlorite as an Irrigation Solution. ....................................... 82 Hand Hygiene ...................................................................................................... 83 Use of Nitrous Oxide ........................................................................................... 85

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Infection Control
POLICY: All students, faculty, and staff must, read the Manual on Infection Control and Environmental Health and Safety, and attest to and adhere to the published guidelines of infection control.

PURPOSE:

To ensure all patients are treated with “Standard Precautions” in an appropriate manner to prevent cross contamination and maintain asepsis.

PROCEDURE:

1.

All patients are treated with “Standard Precautions” as outlined in the infection control manual.

2.

Students, Faculty, and Staff found to be non-compliant are required to attend a remedial class on infection control.

3.

Students, Faculty and staff who continually are found to be non-compliant will be suspended from clinical activity.

4.

The policies are to be monitored by faculty and staff who report such violations to the Committee on Infection Control.

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Recall of Sterilized Instruments
POLICY: All instruments are dated prior to sterilization with the date of sterilization.

PURPOSE:

To insure that in the event of an autoclave malfunction a recall of all instruments sterilized between the last good spore test and the failed spore test can be reprocessed.

PROCEDURE:

1. All instruments packaged for sterilization shall be dated with the date of sterilization.

2. Spore testing is done on a weekly basis. Bowie Dick Tests are run daily.

3. In the event of a positive spore test all instruments sterilized from the date of the last negative spore test through the last cycle shall be recalled.

4. All the instruments that fit into the above category shall be re-sterilized in another autoclave or once two successive spore tests are negative

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Columbia University Health Care Manual of Health Information Policies

Instrument Processing
POLICY: All instruments and handpiece used in intra-oral care must be sterilized and maintained sterile until used.

PURPOSE:

To insure that all instruments used are sterile.

PROCEDURE:

1.

At the end of each procedure all instruments and handpiece used shall be removed from the patient care area.

2.

Instruments that can be ultrasonically cleaned shall be packaged in trays and submitted for ultrasonic cleaning.

3.

Instruments that cannot be ultrasonically cleaned shall be cleaned by hand using heavy utility gloves with an enzymatic cleaner.

4.

Instruments that are cleaned must then be packaged for sterilization.

5.

Trays and packaged instruments must be submitted to central sterilization (VC8) for processing in the decontamination area.

6.

Once submitted instruments that can are cleaned via ultrasonic means.

7.

Cassettes are packaged, sealed and dated with the date of sterilization.

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Columbia University Health Care Manual of Health Information Policies

8.

Instruments are sterilized and maintained sterile in a supply area until used.

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Instrument Requests and Returns
POLICY: All instrument requests and returns must be documented.

PURPOSE:

To insure the security of clinical instruments

PROCEDURE:

1.

Requests for instruments and rental equipment DDS candidates must be made in writing using an instrument request form (IRF). Postdoctoral Instruments are moved by central sterile.

2.

Instruments and equipment must be on separate forms.

3.

The duplicate IRF must be completed by the requesting student.

4.

The student presents the completed IRF to the dispensary and when they receive all requested supplies signs the IRF.

5.

The top copy is given to the student. In the case of instruments the bottom copy is sent to central sterile while in the case of equipment the bottom copy remains at the dispensary.

6.

When returning instruments for sterilization or equipment at the dispensary the student must present the top copy. Module personnel must match the IRF forms (numerical) and sign that they have received the item.

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Columbia University Health Care Manual of Health Information Policies

Dress Code for Clinical Care
POLICY: All DHCW (Dental Health Care Worker) must adhere to the required clinical dress code.

PURPOSE:

To insure appropriate dress during the provision of clinical care.

PROCEDURE:

1.

All FACULTY/STUDENTS/STAFF MUST wear DISPOSABLE GOWNS WHEN IN THE CLINIC.

2.

ALL STUDENTS MUST WEAR DISPOSABLE GOWNS WHEN PROVIDING CARE IN THE CLINIC. BLUE OPERATING ROOM SCRUBS ARE NOT ALLOWED OUTSIDE THE HOSPITAL OPERATING ROOMS.

3.

Disposable gowns should be changed daily or when they become visibly soiled. They can be disposed of in normal waste.

4.

MASKS AND PROTECTIVE EYEWEAR MUST BE WORN AT ALL TIMES WHEN SPLATTER, SPLASH OR AEROSOL PRODUCING PROCEDURES OR OBSERVATIONS OF PROCEDURES ARE BEING DONE.

5.

GLOVES MUST BE WORN AT ALL TIMES WHEN EXAMINING PATIENTS AND PROVIDING CARE. GLOVES MUST BE REMOVED WHEN LEAVING THE CLINICAL AREA. GLOVES MUST BE REMOVED WHEN LEAVING THE OPERATORY.

6.

Head coverings are required in the event there is intrusion of hair into the operating field. Bonnets will be provided when needed.

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Columbia University Health Care Manual of Health Information Policies

7.

Monitoring of activity will be done and failure to comply with the dress code as stated will result in loss of clinical privileges:

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Columbia University Health Care Manual of Health Information Policies

Professional dress code for students, faculty and staff
POLICY: Students, faculty and staff are expected to present a professional appearance at all times.

PURPOSE:

To present a professional appearance.

PROCEDURE:

1. Students, Faculty and Staff are expected to be clean, well groomed and dressed in a manner appropriate to their responsibilities.

2. In positions where continuous contact with the public is required, the following types of clothing are NOT appropriate for the work place: jeans, overalls, sweat shirts, sweat pants, shorts, leggings, halters, tank tops, tee shirts, work-out clothes, sandals or opentoe shoes. Sneakers are acceptable if clean and presentable.

3. Suggested acceptable attire includes: Shirt, tie, slacks, skirt, blouse, and dresses. Scrubs, except operating room blue, are acceptable but must be clean, pressed and changed daily.

4. Students, Faculty and Staff must maintain a professional appearance even though patients may not be scheduled in their area on a given day.

5. Students, Faculty and Staff must maintain an optimum level of personal hygiene.

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Waste disposal
POLICY: All bio-medical and non-biomedical waste shall be disposed of in an appropriate manner.

PURPOSE:

To ensure the effective and appropriate means of disposing of bio-medical and non-biomedical waste.

PROCEDURE:

1.

Waste should be segregated into biomedical waste and non-biomedical waste.

2.

Non-biomedical wastes are those items not visibly contaminated with blood. These should be disposed of in NON-RED BAG containers.

3.

Biomedical waste that is not considered sharp should be disposed of in identified RED BAG containers. This includes those items that are visibly contaminated by blood.

4.

Sharps MUST be disposed of in puncture resistant containers. This includes needles, glass, scalpel blades, orthodontic wires, irrigation syringes, anesthetic cartridges, etc. When the container is full it should be sealed and placed next to the red bag containers for disposal. A new container should be requested from the supply area. UNDER NO CIRCUMSTANCES SHOULD THIS CONTAINER ONCE SEALED BE PLACED IN THE NORMAL NON-BIOMEDICAL WASTE CONTAINERS OR THE RED BAG BIOMEDICAL WASTE CONTAINERS.

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Columbia University Health Care Manual of Health Information Policies

Incident Reports
POLICY: All incidents occurring within the clinical facility shall be reported by the appropriate form to the appropriate people.

PURPOSE:

To insure that all incidents are reported in the appropriate way.

PROCEDURE:

1.

All patients or students injured in the clinical facility should file an "Accident Report - General Liability". These forms are available in the Clinic Administration Office located at PH-7 Stem room 125.

2.

Any patient who is injured during the course of treatment should have an Accident Report filled out and an appropriate notation made of the incident in the chart.

3.

The notation must be accompanied by student and faculty signature.

4.

All employees sustaining an injury in the clinics should file a "Departmental Accident Report". This form is available in the Clinic Administration Office.

5.

In the case of employees they will be referred to employee health for medical care.

6.

In the case of students they will be referred to student health.

7.

In the case of a patient they will have the choice of seeking care with their

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private physician or be referred to the emergency room.

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Receipt, Cleaning, Decontamination, Disinfection of Reusable Items
PURPOSE: To establish written guidelines for the receiving, decontamination, cleaning and disinfecting of reusable items.

PROCEDURE:

1.

RECEIVING A. All items to be decontaminated, cleaned or disinfected will be received in the decontamination room only. B. Personnel delivering items for processing will not enter the decontamination room. C. Personnel assigned to work in the decontamination room will receive items at the window. D. All items received in the decontamination room will be handled as contaminated items to ensure the safety of personnel. E. Personnel should inspect for protruding instruments from cassettes and sterilization pouches.

2.

INSTRUMENTS A. All instruments will be sorted by the set, tray or cassette. Components of sets will be processed together. B. Ring handled instruments, excluding towel clips, will be opened and separated to ensure proper cleaning. C. All surgical instruments will be soaked in an approved enzyme solution for a minimum of 15 minutes. D. All instruments that can, will be processed in the Ultrasonic Cleaner-Rinser Drier. E. Instruments not in cassettes will be placed in processing baskets as complete sets to be processed thru the Ultrasonic Cleaner-Rinser Drier. F. All instruments will be inspected for cleanliness.

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G. Assemble the tray or set using the tray instrument lists. Instruments must be counted two (2) times.

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Assembly, Wrapping and Instrument Sterilization
PURPOSE: To establish a written procedure for clean reusable items to be assembled, wrapped and terminally sterilized.

PROCEDURE:

I.

Assembly and wrapping

1.

Instrument Trays (non-cassette). A. Inspect instruments for proper function and cleanliness. B. Trays and sets are to be assembled using the tray guide. C. Instruments are to be placed in the order that is listed on the tray guide. D. All instruments are to be placed on the tray in an open position to ensure sterilization. E. Place a chemical process indictor within each tray or package to be sterilized. F. Use a disposable wrapper, choosing appropriate size and density for item or sterilization container. G. If needed, tape the wrapper closed using the proper sterilization process indicator tape. H. Label and initial the completed tray, set, kit or linen pack on the tape. I. Place a control label on each item to be sterilized.

2.

Single packed items and Cassettes A. Inspect all instruments for alignment and cleanliness.

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B. Items sterilized in paper plastic peel pouches will be placed within the pouch to allow for student identification number to be visible and proper aseptic presentation when the pouch is opened. C. A chemical process indicator will be included within each peel pouch. D. The peel pouch is to be heat or self sealed and inspected for proper closure after sealing. E. Place a control label on each item to be sterilized. F. Label the pouch, only the plastic side of the pouch or the paper seal may be written on.

3.

Shelf Life Statement: A. Items are sterile unless the integrity of the package has been compromised. If packaging has been torn, instruments dropped, soiled or used, item should be returned to central sterile for reprocessing. B. Single use supplies – disposable supplies designed for single use must be discarded and should not be resterilized. Supplies with questionable integrity of packages must not be used. C. Each dispensary and clinic will reflect an “Event Related Statement”.

4.

Shelf Life Statement: Sterile items that are received from outside manufacturer. Items that are sterilized by outside manufacturer should include either/or: A. The expiration date: If the expiration date is outdated, the item should not be used. B. Event related statement: If the item has an “event related statement” such as “this item is sterile until used” this item is safe for use until the packaging has been compromised.

II.

Sterilization

1.

Sterilization

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A. Loading of the sterilizer carts must allow for free circulation of steam around each item. Caution must be taken not to overload the cart. Any item capable of holding water, e.g. basin sets, must be positioned in such a way to allow the water to drain out. B. All sterilizers are to be operated following the manufacturers written instructions. C. All items removed from the steam sterilizer must be allowed to cool before handling. D. Any item that appears to be wet when removed from the sterilizer will be considered contaminated and must be reprocessed. E. Handle sterile packs and trays as little as possible.

2.

Sterile Storage A. Sterile supplies are to be stored at least eight (8) inches from the floor and at least eighteen (18) inches from the ceiling and at least (2) inches from the wall. B. Care must be taken not to crush, bend, puncture or compress sterile items. C. Sterile supplies must be rotated (first in, first out). D. Cardboard boxes are not allowed in the sterile storage area. E. When issuing an item from the sterile storage area, the package should be inspected for integrity prior to issuing.

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Columbia University Health Care Manual of Health Information Policies

Autoclave Loading
PURPOSE: To ensure proper loading of the autoclave

PROCEDURE:

1. While loading and unloading sterilizer, appropriate personal protective equipment must be used.

2.

Loading the steam sterilizer.

A. Place textile packs on edge to promote passage of steam through the pack. B. Place fabric packs on top shelves of a loading cart when combining the load with hard goods. C. Do not overload shelves D. Do not compress packages E. Do not allow packs to come in contact with the chamber wall. F. Allow at least 3 inches between the chamber ceiling and the topmost package of the load. G. Do not place anything on the chamber floor. H. Place paper/plastic pouches on edge with the plastic side of one facing the paper side of the one next to it. If the pouch must be placed flat, the paper side should face down. I. Do not stack pouches.

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Cleaning Procedures for Sterilizers
PURPOSE: An autoclave is an apparatus used for sterilizing objects by steam under pressure. Weekly cleaning of the autoclave is necessary to keep the apparatus clean and free from scale and rust and lint. Daily cleaning of the autoclave’s exterior is necessary to keep clean and free of dust particles and lint.

PROCEDURE 1. Weekly cleaning procedure of Autoclave Chamber: Use Trisodum Phosphate (Calgonite) as recommended, at one (1) ounce per gallon of water. Use this solution on the inside of the autoclave door. Use a dampened cloth, soft brush or sponge mop to clean entire inside of chamber. NEVER USE ABRASIVE CLEANING COMPOUNDS, WIRE BRUSHES OR STEEL WOOL INSIDE CHAMBER.

2.

Weekly Flushing of Autoclave Drains: Dilute one (1) ounce of Scale-Gon (Calgon Corporation) to eight (8) ounces of hot water and pour the solution slowly down the autoclave drain. After five (5) minutes, pour three (3) quarts of water down the drain to rinse out the Scale-Gon.

3.

Weekly final flushing of Autoclave Drain: Dissolve two (2) ounces of Calgonite in sixteen (16) ounces of water, and pour down the autoclave drain. Let stand for five (5) minutes and then flush with three (3) quarts of water to rinse.

4.

Daily cleaning of Autoclave exterior and stainless steel counter tops: Use stainless steel cleaner for door and sides of the autoclave, and the counter tops in all areas removing dust particles. Repeat procedure as visibly needed.

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Sterilizer Failure Recall
PURPOSE: To establish a recall procedure for sterilized items in the event of a positive biological test on a sterilizer, indicating sterilizer failure.

PROCEDURE:

1.

In the event of a positive biological test.

A. Discontinue use of the sterilizer that produced the positive test. B. Recall all items processed in the sterilizer since the last negative biological test. The items will be determined by the load cards for that sterilizer and control label. C. Notify all appropriate user departments by telephone of the load numbers and items being recalled. D. Notify all appropriate user departments in writing of the load numbers and items being recalled. This recall notice is to be co-signed by the Associate Dean for Patient Care. E. Make the necessary arrangements for the repair of the equipment in question F. Prepare a recall report which will: 1. Identify the circumstances for the recall 2. Specify corrective actions to prevent recurrence. 3. State total items intended to be recalled. G. Forward the recall report to the Infection Control Committee.

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Columbia University Health Care Manual of Health Information Policies

Dress Code for Instrument Processing
POLICY: All personnel working in central sterilization processing instruments must wear appropriate attire.

PURPOSE:

To ensure appropriate attire for the processing of instruments

PROCEDURE:

I.

Work Attire

1. The proper attire for the central sterile department will be a disposable gown. A new disposable gown is to be used each day unless it becomes visibly soiled. In the event it becomes soiled, a new gown must be used.

A. The disposable gown is to be removed when leaving the area. B. While in the central sterile department, each employee will wear shoe covers and a surgical cap or hood that covers all hair, including sideburns and beards. Shoe covers are to be changed each time an employee leaves and returns to central sterile.

1.

ANY EMPLOYEE ASSIGNED TO WORK IN THE DECONTAMINATION ROOM WILL WEAR DISPOSABLE GOWN, FACE MASK WITH SHIELD, GLOVES AND SHOE COVERS. GOWNS, GLOVES AND SHOE COVERS ARE TO BE REMOVED WHEN LEAVING THE DECONTAMINATION ROOM. Hands must be washed each time gloves are removed. If any garment becomes wet due to splash of liquid, the garment is to be changed at once.

2. 3.

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Columbia University Health Care Manual of Health Information Policies

4.

Any puncture wounds or liquid splashes are to be reported to the supervisor on duty at once.

2. Any visitors to the department will be instructed to wear a gown, head cover, and shoe covers before being allowed entry to the department.

II.

Hygiene

A. B. C.

Cleanliness and good hygiene are mandatory. Hair, body and nails should be clean at all times. Clean shoes should be maintained by personnel; soles of shoes should be of non-skid design. Shoes should be hard toe to prevent injury if an item drops on foot. Excessive jewelry should not be worn. This includes large dangling or loose jewelry.

D.

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Columbia University Health Care Manual of Health Information Policies

Biological Monitoring: Spore Testing
PURPOSE: Biological indicators are used locally on a daily basis and weekly in microbiology for the steam sterilizers to document the efficacy of steam sterilization cycles under use conditions.

PROCEDURE: A. Exposure

1. Identify the indicator by writing the sterilizer, load number, and the processing date on the vial label. 2. Indicator is located in center of test pack. 3. The test pack consists of pre-assembled disposable materials and is designed to consistently challenge the sterilization cycles. 4. Place the test pack on the bottom shelf of the cart near the door. This is the most challenging area in the sterilizer. 5. Allow the test pack to cool for a sufficient amount of time in order to cool the indictor. 6. Indicator must be sent to microbiology weekly within 2 hours. If these instructions are not followed, the spores will die off at room temperature and a sterilization process failure may go undetected. 7. Microbiology processes the indicator and informs clinic administration with results.

B.

Documentation

1.

All biological results for sterilization will be recorded. The documentation will consists of the following: a. b. Date, sterilizer and load # Results

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Columbia University Health Care Manual of Health Information Policies

Sterilization Indicators
PURPOSE: To establish a procedure for the use of Chemical Sterilization Indicators.

PROCEDURE:

1. A chemical sterilization process indicator will be included with each sterilized item. 2. The indicator will be placed as close to the geometric center of the package as practical. 3. Each package wrapped for sterilization will be taped closed with a tape which has been chemically treated to indicate the package has been through the sterilization process. 4. Paper plastic peel pouches will have a chemical sterilization process indicator placed within the package in a manner that it will be readable through the plastic side of the pouch. 5. A color change in the chemical sterilization process indicator shows that the package has been exposed to the conditions for sterilization, they do not guarantee sterility.

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Columbia University Health Care Manual of Health Information Policies

Bowie & Dick Test Pack
PURPOSE: To establish a method of function testing for pre-vacuum sterilizers.

PROCEDURE:

1. The Bowie and Dick test shall be conducted on each pre-vacuum sterilizer first thing in the morning on a daily basis.

A.

Place a pre-assembled, disposable test pack in the horizontal position on the lowest shelf (above the drain) of the empty sterilizer. (The Bowie & Dick protocol requires that only the test pack may be in the sterilizer during the test.) Run a sterilization cycle: The exposure time to 3 minutes at 272 degree F (270274 degree F of 132-134 degree C) Omit drying cycle. After the test, remove the pack from the autoclave. CAUTION: OPEN DOOR CAREFULLY DUE TO POSSIBLE P RESENCE OF STEAM. Open the pack. Remove the Bowie Dick test sheet from the center and interpret the result. A uniformly black color of the concentric lines is an indication of a pass. The presence of an area where the indicating ink has not yet changed to black is a possible indication of a failure. The color of the incompletely changed area may be dark brown, light brown, or the original white color of the unreacted indicator ink. Overexposure caused by excessive temperature, time, or both will cause the black endpoint color to shift to an overall gray tone. Since the test requires the appropriate exposure conditions, a test resulting in an overexposed test sheet is not valid and the test must be repeated with Correct exposure conditions. (If an indication of overexposure is observed when the correct exposure time is used, the temperature adjustment on the sterilizer may not be accurately calibrated and may require the attention of a qualified mechanic.

B.

C.

D.

E. F.

G.

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Columbia University Health Care Manual of Health Information Policies

H.

The date, the sterilizer number and the operator’s initials must be entered on the Bowie & Dick sheet following the test. File the sheet with the appropriate records for that sterilizer. Any result other than a pass must immediately be brought to the attention of the supervisor who will determine whether or not the sterilizer can be used that day of if it must be shut down until repaired.

I.

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Disposal of extracted teeth (REFERNCE/attach Amalgam Algorithm)
POLICY: Handling of extracted teeth and hard tissue specimens.

PURPOSE:

To store, dispose or send for pathology of extracted teeth appropriately.

PROCEDURE:

1. All hard tissues removed must be evaluated.

2. If upon gross inspection it is determined that histologic evaluation is required, the specimen must be placed in the appropriate specimen bottle, a requisition for oral pathology completed and sent to the laboratory.

3. If upon gross inspection it is determined that histologic evaluation is not required, the extracted teeth must be placed in the appropriately labeled (extracted teeth) container.

4. Containers for extracted teeth are located in oral and maxillofacial surgery and the postgraduate periodontal clinic. Transport containers are available at the VC-8 dispensary if teeth need to be transported to these containers.

5. Transport containers as well as main containers have a solution of sodium hypochlorite (1 part bleach, 9 parts water).

6.

Main containers are collected by the University’s contracted vendor through the Office of Environmental Health and Safety who maintains waste manifests/certificates of recycling.

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Amalgam Disposal (REFERNCE/attach Amalgm Algorithm)

POLICY:

Scrap Amalgam must be disposed of appropriately

PURPOSE:

To dispose of scrap amalgam according to regulations.

PROCEDURE:

1. Amalgam is only purchased in self-contained unit dose packaging. 2. Triturating self-contained unit dose packages is accomplished according to manufacture direction.

3. Once triturated the capsules contents are emptied in an amalgam well, empty capsules must then be placed in water containing containers labeled non-contact amalgam scrap.

4. Amalgam remaining after the procedure must be placed in water containing containers labeled non-contact amalgam scrap.

5. On a weekly basis, water-containing containers labeled non-contact amalgam scrap must be emptied into the larger scrap amalgam containers located in designated areas.

6. Large scrap amalgam containers are removed as necessary by the Office of Environmental Health and Safety.

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Collection of non-contact amalgam scrap and capsules
POLICY: Non-contact amalgam scrap and capsules will be collected in labeled containers

PURPOSE:

To collect all unused amalgam scrap and capsules and dispose of appropriately

PROCEDURE:

1. Do not dispose of amalgam waste in regular trash or infectious waste.

2. The remaining amalgam scrap and capsule after completion of the procedure must be collected.

3. The collected scrap and capsule must be deposited in a Hazardous waste container labeled “Non-contact Amalgam Scrap.”

4. The container contains water and amalgam scrap. It is labeled as Hazardous Waste.

5. Containers will be collected by the Office of Environmental Health and Safety’s contracted vender on an as needed basis.

6. Only amalgam scrap and capsules should be placed in the container.

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The Collection and Disposal of Lead Foil
POLICY: The collection and disposal of lead foil must be done according to regulations.

PURPOSE:

To store and dispose of collected lead foil from radiographic packets appropriately.

PROCEDURE:

1. Lead foil removed from radiographic packets cannot be disposed of in regular waste or regulated medical waste containers.

2. Upon opening radiographic film packets, the enclosed lead foil must be collected. The outer wrapper may be disposed of in regular waste, unless visibly soiled with blood, in which case it should be disposed of in regulated medical waste.

3. The foil should not be contaminated with body fluids.

4. The foil should be placed in the container labeled “Collected Lead Foil”.

5. The lead foil will be packaged and collected and sent to the Office of Environmental Health and Safety for recycling by CDM.

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Removal of Radiographic Fixer Solution from self-contained processors
POLICY: The removal of Radiographic Fixer must be done according to regulations.

PURPOSE:

To dispose of fixer solution appropriately.

PROCEDURE:

1. Each area that contains a non-plumbed self-contained X-ray processor must maintain a log of solution maintenance.

2. Each time the fixer is changed, on a non-plumbed self-contained processor, the spent fixer must be disposed of through the closest silver recovery system.

3. The silver recovery systems are maintained by the University’s contracted vendor through the Office of Environmental Health and Safety.

4. Filters for these systems, as well as the centrally plumbed system, are serviced by the contracted vendor and waste manifests/certificates or recycling are maintained by the Office of Environmental Health and Safety.

5. Developer must not be disposed of through a silver recovery system. Developer may be disposed of through normal waste lines.

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Collection radiographic film
POLICY: All used or unused radiographic film must be disposed of in appropriate labeled containers.

PURPOSE: To ensure compliance with disposal of silver waste accordance with the (federal, state and city) regulations.

PROCEDURE:

1. Containers clearly labeled “Scrap Films Only” will be placed in appropriate areas.

2. Scrap films, either developed or undeveloped, must be removed from folders or envelopes and placed in these containers.

3. Every effort should be made to avoid placing other materials in these containers.

4. Environmental Health and Safety will collect scrap films quarterly.

5. Scrap film should be collected when you purge your files, trim your useable or unusable films or otherwise choose to dispose of your film.

6. Scrap film includes: Medical films, Dental x-ray film, professional black and white and color films and negatives, x-ray films for non-destructive testing, x-ray films for radiography, all other imaging films processed through wet chemistry methods.

7. Contact Environmental Health and Safety at 305-6780 if containers need to be picked up sooner.

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Use of Sodium Hypochlorite as an Irrigation Solution
POLICY: All Sodium Hypochlorite removed from its original container MUST be placed in an appropriately labeled container.

PURPOSE:

To ensure that all liquids can be appropriately identified when removed from the original container.

PROCEDURE:

1. When using Sodium Hypochlorite as an irrigation solution it shall be removed from its’ original container. 2. It shall be poured into a container with a lid. 3. The container shall be labeled Bleach Poison. 4. The use of Sodium Hypochlorite as an irrigation solution shall only be done with strict Rubber Dam Isolation. 5. At the end of the procedure the solution may be disposed of in normal waste.

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Hand Hygiene
PURPOSE: To ensure proper Hand Hygiene in the dental clinical environment.

POLICY:

Hand Hygiene must be performed to prevent the spread of infection.

BACKGROUND: Hand Hygiene refers to the use of alcohol-based hand sanitizers and/or soap and water. Alcohol-based hand sanitizers are the agent of choice. Only approved hand hygiene agents are permitted.

PROCEDURE:

Alcohol based Sanitizer Protocol A. When to de-germ hands with alcohol-based hand sanitizers: a. Before and after patient contact b. After touching patient care equipment or environmental surfaces. c. Before performing invasive procedures d. Before placing gloves. e. After removing gloves. B. How to use the alcohol based sanitizer: a. Apply enough gel to entirely cover all surfaces of hands and fingers including under the fingernails. b. Spread the solution onto all hand surfaces including between fingers, backs of hands up to wrists. c. Continue rubbing hands together until dry.

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Hand Washing Protocol A. When to wash hands with soap and water: a. At the start of the day. b. If hands come in contact with blood or body fluids c. When hands are visibly soiled d. If hands are sticky after multiple applications of an alcohol based hand sanitizer. e. After using the lavatory. B. How to wash hands a. Wet hands thoroughly leaving the water running. b. Apply soap to the palm of one hand c. Rub hands together creating friction for at least 15 seconds. d. Thoroughly covering all areas including backs of hands, between fingers, under fingernails and thumb. e. Rinse hands while keeping fingers pointing downward to allow soap and water to run off of fingertips. f. Dry hands with paper towels.

g. Turn the faucets off, if not automatic or leg operated, using paper towels.

Skin Care A. Frequent and repeated use of Hand Hygiene products is a primary concern for chronic irritation and dermatitis. This can cause increased risk for bacterial colonization with staphylococci and gram-negative organisms. B. Alcohol based hand sanitizers with dermaglycerin decreases this risk. C. Staff should not share personal hand lotions or creams.

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Use of Nitrous Oxide
Policy: environment. To minimize potential exposure to nitrous oxide and provide a safe working

Purpose:

To maintain nitrous oxide delivery system to minimize exposure.

Procedure: The following practices will be observed where nitrous oxide is used as an anxiolytic or analgesic in clinical locations:

1. Delivery System Checks: Nitrous oxide holding tanks will be secured according to applicable codes and checked for leaks after connection. Nitrous oxide delivery units will be serviced by the Biomedical Engineering on an annual basis. Nitrous oxide delivery units will be monitored, at a minimum, on a monthly basis using TIF Leak Detector. This includes all hoses, fittings, connections, and reservoir bags. Wall connections will be monitored, at a minimum on a monthly basis. The nitrous cut off will be secured at the end of each day.

2. Equipment Maintenance Anesthesia-delivering machines shall be maintained per manufacturer recommendations. Equipment shall be checked monthly for worn parts and replaced as necessary. Equipment found not working should be tagged and removed from service.

3. Ventilation System Checks

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Air supply grilles and exhaust vents will be checked, at a minimum on a monthly basis, with a kim wipe. The room entrance door, when feasible, will be kept closed during use of nitrous oxide to prevent blocking of exhaust system. The ventilation system will be measured annually to ensure adequate air changes per hour in all rooms using nitrous oxide.

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4. Monitoring The ambient release of nitrous oxide will be measured annually in rooms using N2O. Personal samples may be taken when necessary. 5. Training Training in the Safe Use of Nitrous Oxide will be provided to employees involved in its use, maintenance and delivery. Training will be provided on an annual basis.

6. Record keeping A log of monthly and annual maintenance checks will be maintained. Records of training and monitoring will be maintained.

Responsibilities: 1. CDM Implement this policy at its sites Assign and train individuals to perform monthly and annual checks on nitrous oxide delivery system and use Maintain a log of all maintenance checks. Arrange with Facilities Operations for annual ventilation system performance check. Coordinate with EH&S for annual monitoring and training.

2. EH&S Arrange with the outside vendor for annual monitoring. Provide nitrous oxide safety training annually. Maintain records of training and monitoring.

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3. Facilities Operations Work with CDM for ventilation maintenance checks to ensure proper functioning of the system and 12 air changes per hour.

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Content – Health Information Policies
Access To Patient Information ...................................................................................................... 90 Purging inactive patient records ................................................................................................. 102 Introduction --Patient Records Department ............................................................................... 104 Objectives of the Patient Records Department .......................................................................... 107 Use of Patient Records ................................................................................................................ 109 Safeguards of Records and Computerized Data from Damage, Loss or Tampering. .................. 111 Color Coding of Patient Record Folders ...................................................................................... 114 Arrangement of Patient Record .................................................................................................. 115 Retrieval of Patient Records ........................................................................................................ 118 Filing of Loose Forms ................................................................................................................... 120 Disposal of Confidential Documents. .......................................................................................... 121 Confidentiality of Patient Records /Patient Information ............................................................ 128 Schedule of Fees for Processing Request for Patient Information.............................................. 140 Patient Record Requisition. ......................................................................................................... 142 Confidentiality of Patient Records Containing HIV-Related Information .................................... 146 Dental Record Completion .......................................................................................................... 152 Filing of Patient Records. ............................................................................................................. 153 Health Information Forms ........................................................................................................... 155 Informed Consent........................................................................................................................ 156 Medical Alert Stickers .................................................................................................................. 158 Dental Record Duplication .......................................................................................................... 159 Facsimile of Patient Information ................................................................................................ 160

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Access To Patient Information
POLICY: Public Health Law Section 18 and Mental Hygiene Law Section 33.16 establish a patient or other qualified person (parent, legally appointed guardian, appointed committee and/or person for any incompetent person) the right of access to patient information. Such access will be granted in accordance with the following established procedure.

PURPOSE: To comply with New York State Public Health Law, effective January 1, 1987 in relation to access to patient information.

RESPONSIBILITY: All Employees, Students, Residents and Professional Staff

I. Definition of Patient Information that is Accessible Under Section 18

The law broadly defines patient information to mean any information concerning or relating to the examination or treatment of a patient, which is maintained or possessed by the provider or practitioner who has treated or is treating the patient. This includes both inpatient and outpatient information.

“Treatment” does not include diagnostic tests performed at the request of another practitioner provided that access to such tests can be obtained by means of an access request directed to the practitioner who ordered the test.

Specifically excluded from the above definition of patient information are the following:

Information and clinical records subject to the provisions of 23.05 of the Mental Hygiene Law (right of patients in substance abuse programs) or Section 33.13 of the Mental Hygiene Law (confidentiality of clinical records of mental health patient) with respect to access of records of such patients.

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Patient information maintained by the practitioner concerning or relating to the prior examination or treatment of the patient, which was received from another practitioner.

Information that is specifically disclosed to a practitioner in “confidence” by the other persons with the express condition that such information would never be made available to the patient or any other person. This information may be deemed subject to access if the information is ultimately disclosed.

Personal notes, observations, speculations, impressions (other than tentative or actual diagnosis) and reminders maintained by the practitioner provided that they are not disclosed to any other person. However, for purposes of this paragraph, disclosure to the following persons or entities shall not qualify as disclosure to “any other person”.

Practitioners, as part of a consultation or referral during treatment of the patient.

Persons reviewing information or records in the ordinary course of ensuring that a provider is in compliance with the applicable quality of care, licensure, or accreditation standards.

Governmental representatives for the sole purpose of conducting an audit in the course of his or her official duties.

Persons pursuant to a court order.

Governmental agencies, licensed insurance carriers and other third-party payers who require information in order to make payment on behalf of a patient for care provided.

Qualified researchers.

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The State Board of Dentistry when such Board requests information in the exercise of its statutory functions.

An insurance company insuring or attorney consulted by a provider or certified HMO.

The Patient Record Access Review Committee or a court, which is reviewing a decision by a provider to deny access under Section18 of the Public Health Law.

II. Persons Defined as Qualified to Gain Access to Patient Records

A. Qualified persons are defined by Public Health Law Section 18 as “The subject (patient), guardian appointed under Article 81 of the Mental Hygiene Law, a parent of an infant or a guardian of an infant appointed by the court, a distribute of any deceased subject for whom no personal representative, as defined in the Estates, Powers, and Trust Law, has been appointed, an attorney representing a qualified person, or the subject’s estate who holds a power of attorney from the qualified, or the subject’s estate explicitly authorizing the holder to execute a written request for patient information.”

Examples: 1. The patient 2. The parent of an infant patient (exception – see III Disclosure of Patient Information of Infants) 3. The Committee of an incompetent patient 4. The lawfully appointed guardian of a patient 5. An attorney representing or acting on behalf of the subject or the subject’s estate. 6. The health care provider directly involved in the patients care

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III. Disclosure of Patient Information of Infants

A parent or guardian may request patient information where the consent of the parent or guardian for the treatment of the minor child, or in the minor child’s relationship with his or her parents or guardian.

A. Upon receipt of a request for disclosure of patient information of a minor by a parent or guardian, the previous stated exceptions will be considered.

B. Any patient over the age of twelve (12) years may be notified of any requests by a parent or guardian to review his or her patient information. If the minor child over the age of twelve (12) objects to disclosure, the University will deny the request. The treating provider is also to be consulted prior to granted or denying access to patient information on minors to parent or guardian.

C. The record must be carefully inspected to ascertain that the patient information does not contain sensitive materials. Such sensitive materials would be sexually transmitted diseases, pregnancy, child abuse, and/or substance abuse.

D. If the parent or guardian is denied access and continues to seek access, they must avail themselves to the review process under the statute.

IV. Coordination of Requests

A. All request for access to patient information are to be coordinated through the Patient Records Department.

1. If ancillary departments receive requests for access to patient information, the caller is to be advised to submit his/her request in writing to the Patient Records Department.

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2. If ancillary departments receive requests for access in writing, these requests are to be hand delivered to Patient Records Department upon receipt of request by that department. 3. Prompt action by ancillary departments in the event of a request for access is mandatory due to the statutory requirement that all requests for access be acknowledged within a very limited time period

V. Procedures for Gaining Access to Patient Records

A. Inspection A patient can request to see his/her notes and be guided by the care provider through the contents with explanations of “terminology and technical language.”

1. Upon receipt of a written request from the patient or other qualified person (see definition II – Page 3), the opportunity to inspect the patient records must be provided within ten (10) business days.

a. Requests for inspection must be in writing and must provide sufficient information to identify the patient and the qualified representative if other that the patient has access. b. The patient or other qualified person shall provide verification of identity or photo identify prior to inspection. Individuals requesting inspection in the capacity of a guardian or conservator shall provide a copy of their appointment papers. c. The requested patient information will be reviewed prior to inspection to ensure completeness and to determine if any exceptions to access, as defined in the law. (New York State Law) d. The primary provider will be notified both by telephone and in writing within 24 hours of receipt of this request that a patient or other qualified person wants to inspect the patient records. He/she will be advised that the information requested is available for his/her review if he/she so desires. Primary provider is defined as the attending provider with primary care responsibility for the patient.

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e. The form is to be completed by the primary attending provider and returned to the Patient Records Department within five (5) days of receipt. This form request documentation of approval or denial of access. f. If the provider approves, the patient or other qualified person may gain access to the patient information requested in accordance with procedures set forth herein.

g. If the provider disapproves access, there should be a direct consultation with the Director of Patient records or designee. The primary provider must document the reason for denial of access on the form. h. If the provider does not respond either affirmatively or negatively within the stipulated time period or if he/she is unavailable at the time of the request, the University reserves the right to request an alternative provider review the request for access. If the primary attending provider is no longer on the professional Staff or employed by the University the appropriate Chief of service and/or Patient Director will be notified to review the request for access. i. If there is a problem meeting time constraints this must be brought to the attention of the Director of Patient Records or designee. All requests will be acknowledged in writing and include information regarding hours and place of inspection, charges and collection procedures.

j.

k. Inspection of records will be permitted in the Patient Records Department on Monday through Friday between the hours of 8:00 a.m. and 2:00 p.m. by appointment only. No inspections will take place on holidays and weekends.

All persons gaining access to patient records must comply with all rules and regulations of the Patient Records Department. Under no circumstances shall any person be permitted to write in the patient record and pens shall not be permitted in the review area. Persons seeking review of the patient record shall sign a statement acknowledging their obligation to comply with these general rules.

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l.

The fee for inspection of the patient record is $15.00, payable to the cashier prior to inspection. This charge is subject to modification. Note: If the qualified person cannot pay this fee, access cannot be denied solely on that basis.

m. Inspection will be carried out under the direct visual supervision of a designated Patient Records Department staff member. n. Procedures for notification of the primary provider, etc. need not be reinstituted where a request for a photocopy of the patient record follows immediately after completion of inspection to the patient record.

2. In any situation where there is a notice of claim, pending action or threat of litigation, the Director of Patient Records or designee is to be notified and a copy, rather that the original, will be provided for inspection. The Risk Management office is to review all such requests for access to patient information.

a. The patient or other qualified person shall provide verification of identity or photo-identify prior to receiving copies of information, i.e. driver’s license or major credit card or photo identification. Individuals requesting copies in the capacity of a guardian or conservator shall provide a copy of their appointment papers.

B. Deceased Patient a. If there is no personal representative appointed or holder of Power of Attorney from the patient, the distributee can request the deceased patient information. A copy of a certified copy of the certificate of death shall be attached to the written request. b. If the deceased holder power of attorney is requesting the patient information, a copy of Power of Attorney shall be attached to the written request. Such request is subject to duration and term of Power of Attorney. c. Distribute Hierarchy 1. Spouse

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2. Child/Children 3. Grandchild/Grandchildren 4. Parent(s) 5. Siblings(s) 6. Grandparent(s) d. If there is a personal representative appointed for the deceased, the distribute no longer has a right to access the deceased patient’s information. e. There may be other regulations for confidential HIV related information, termination of pregnancy, treatment for a sexually transmitted disease, mental health and other sensitive information in the deceased patient’s record. C. Copies

1. Upon receipt of a request form the patient or other qualified person, Columbia University Health Care shall furnish photocopies of the patient’s information within a reasonable time period.

a. Request for photocopies must be in writing and must provide sufficient information to identify the patient and the qualified representative if other than the patient has access. The request shall describe the scope of the information being sought.

b. The patient or other qualified person shall provide verification of identity or photo-identity prior to receiving copies of information, i.e. driver’s license or major credit card or photo-identification. Individuals requesting copies in the capacity of a guardian or conservator shall provide a copy of their appointment papers.

c. The requested patient information will be reviewed prior to its release to ensure completeness and to determine if any exceptions to access, as defined in the law.

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d. The fee for photocopying will be .75 per page to cover copying costs.

2. In any situation where there is a notice of claim, pending action or threat of litigation, the Director of Patient Records or designee is to be notified. The Risk Management office is to review all such requests for access to patient information.

VI. Limitations on Access

A. The provider may deny access to all or a part of the information and may grant access to a prepared summary of the information if, after consideration of all the facts and circumstances, the provider determines that:

1. The request to review the information can reasonably be expected to cause substantial and identifiable harm to the patient or others and that harm outweighs the qualified person’s right to access.

2. The material is personal notes and observations, or;

3. The requested information would have a detrimental effect on an infant’s care or treatment or an infant’s relationship with his/her parents or guardian.

B. In considering such limitations on access, the provider may also consider, among other things, the following factors:

1. The need for and the fact of continuing care and treatment.

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2. The extent to which knowledge of the information may be harmful to the health or safety of the patient or others.

3. The extent to which the information contains sensitive material disclosed in confidence to the practitioner by family members, friends, or other persons

4. In the case of a minor/patient making a request for access, the provider may consider the age of the minor patient.

D. When access is denied, DOH Form #1989 must be completed and sent to the qualified person making the request.

E. At that point, the qualified person requesting the information has the right to review of such denial without cost, by the appropriate Patient Record Access Review Committee, which is appointed by the Commissioner of Health (see Section VII).

1. The qualified person making a written request to the University commences a request for review by the Committee.

2. The statute states no time period when such a request has to be made by the qualified person.

3. Within ten business days of receiving a request for review, the University is required to provide all patient information including personal notes and observations to the Chairman of the Patient Records Access Review Committee with a written statement of the specific reasons for denying access.

VII. Patient Records Access Review Committee

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A. The New York State Commissioner of Health will appoint a Patient Record Access Review Committee as needed. Members will be licensed providers.

1. This Committee will make a determination as to whether or not access to patient information will be permitted. 2. If the Committee determines that access should be granted, the University must grant access of patient records to the qualified person.

VIII. Secondary Appeal

A. If the qualified person is dissatisfied with the Committee’s determination. The qualified person may seek judicial review of the determination. Any such request for judicial review must be commenced within thirty (30) days after the Committee determination is issued. The relief available from a court is limited to a judgment requiring the provider to make available to the qualified person the requested information for inspection or copying.

IX. Challenge to Accuracy

A. A qualified person may challenge the accuracy of information maintained in the patient record.

1. The qualified person may not change or otherwise revise what has already been entered in the patient record. He or she may request that a brief written statement prepared by him or her concerning the challenged information be inserted in the patient record. 2. Such a statement then becomes a permanent part of the patient record and is required to be released whenever the information at issue is released. 3. Such challenges to accuracy only apply to factual statements and not to observations, inferences or conclusion.

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X. Requests to Carry Information to another Health Care Provider

A. Requests by a patient or a patient representative to carry a photocopy of patient information to another health care provider for purposes of expediting the transfer of this information will continue to be honored without charge and without initiation of the Patient Access Policy with the following stipulations:

1. Verbal approval is granted by the attending provider

2. The patient signs a release form

3. The required information is placed in a sealed envelope

B. If the attending physician denies a request by a patient or a patient representative to carry his or her records, the patient may either request that the information be sent by mail or request access.

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Purging inactive patient records
POLICY: To assure sufficient space in the Permanent File Area of the Patient Records Department. Inactive patient records shall be purged on an annual basis, and sent to a contractual company for storage. They shall be retained at the storage company for seven years as required by Statute. In the case of minors, for the period of minority plus any applicable period of time specified in state or federal statute relating to retention of record of minors. Purged records shall be accessible for retrieval.

PURPOSE: To provide guidelines for purging inactive patient records from the permanent file room.

DEFINITION:

Inactive Patient Records: Records for patients who have not been treated at the Columbia University College of Dental Medicine clinics in the past three years are considered “Inactive”.

RESPONSIBILITY: Patient Records Department Staff.

PROCEDURE: 1. Remove all records from the permanent file, one shelf at time.

2. Place records on a cart and check to ensure that all records are in numerical digit order.

3. Review records to determine the last date of patient activity (3years from last date of treatment).

4. Check forms in the records for accuracy of patient information.

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5. For each record being purged, write the patient name, dental record number and the last date of treatment in a “Purging Control Sheet”. (SEE ATTACHED SHEET)

6. All patient information listed on the purging sheet should be entered in an electronic database.

7. Keep original log sheet in a loose-leaf binder for patient record use. Place a copy inside boxes of purged records.

8. Label the boxes with numbers and purging date.

9. Call the company when boxes are ready for pick up.

10. Call the company to recall a record when a record is needed for patient care.

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Introduction --Patient Records Department
PURPOSE: To provide the framework of the Patient Records Department.

INTRODUCTION:

The patient record is an instrument to be used to provide: Consistency and continuity in patient care. Aid in clinical research and studies. Financial document. Legal protection for all concerned Decision analysis. Professional and organizational performance, evaluation and improvement.

The Director of Patient Records

The principle duties of the Director of Patient Records are those basic functions inherent in organizing and managing a patient record system and in providing efficient patient record service. These duties have been defined as: The planning, designing, and technical evaluation of patient information systems. The planning, directing and control of the administration of patient records services. Assistance to the dental staff. Development of statistical and other information reports. Development, analysis and technical evaluation of patient records. Participation in community and professional activities.

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Supervision of the patient record department including safeguarding and securing patient health information contained in patients records.

The Director of Patient Records plays a major role in the development of a functional patient record system.

The quality of the patient record itself and the use made of the information it contains depend to a great extent on the skill and diplomacy demonstrated by the Director of Patient Records in developing a patient record consciousness on the part of the entire staff, on his/her ability to produce information and on his/her willingness to encourage dental staff members and others to utilize the information. The Director of Patient Records in charge has the primary operating responsibility of organizing and managing the department so that it can render the greatest possible service with a minimum of time, effort and expense. This presupposes on his/her part knowledge of the requirements of accrediting and licensing agencies; the laws governing the release of patient information; the comparative efficiency of various systems of numbering, filing and indexing, and also on development in dental record systems and equipment. He/she must be qualified to assist the patient and administrative staff in matters relating to patient records.

The final evaluation of the patient record system will depend on the utilization of recorded information and availability of that information: For the benefit of the patient in the event of future illness.(es) For utilization and peer review.(s) As an aid in clinical and statistical research.(es) As an administrative tool for planning and evaluating the University program. In legal and quasi-legal proceedings For verification of information for third party payers.

Functions of Department

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Chart Room Services

Hours: Monday-Wednesday –7:30am- 6:30 pm. Thursday – 7:30am – 6:00pm Friday – 7:30am – 5:30pm

Function:

Retrieve and file charts for direct patient care (emergencies, clinics, walk-ins), third party billing (Business office), auditing, authorized research, patient access, legal and intradepartmental requests.

Receive, sort and file loose data into patient records for purging, file maintenance and chart control.

Deliver all pre-appointment and walk-in charts to clinical areas or requests when necessary.

Process patient, legal, insurance requests for patient information

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Objectives of the Patient Records Department
POLICY: To Develop objectives for the Patient Records Department.

PURPOSE:

1. To plan, initiate, implement and monitor an efficient and effective Patient Record System.

2. To enforce the policies and procedures by applying Patient Record Management practices in the collection, storage and use of patient care information.

3. To comply with the department needs and mandated accrediting standards and legal requirements.

RESPONSIBILITY: Director of Patient Records.

PROCEDURES:

All objectives shall be accomplished by: Adequate, well trained and supervised staff to perform effectively and efficiently the functions involved in the development, storage, maintenance and dissemination of patient information. Providing an accurate meaningful and readily accessible record for every patient. The record must be legible, ensuring prompt retrieval of information for continuity of care, reimbursement, research and communication among health care providers. Maintaining an organized and systematic filing and tracking system to facilitate the timely retrieval of a patient record.

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Analyzing and evaluating the record for completeness and verification of data entries including initiation and follow up on other provider’s documentation. Protecting the confidentiality of the patient record by formulating guidelines and policies regarding release of information. Records may be removed form the University only in accordance with a court order or subpoena.

The Patient Record Department is involved in the quality improvement activities. Its responsibilities include: Focusing on known or suspected problem areas affecting the quality of patient care. Developing and implementing controls for all record keeping activities. Advocate of Patient Confidentiality Controlling and securing patient health information against unauthorized disclosure

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Use of Patient Records
POLICY: It is the policy of Columbia University College of Dental Medicine clinics to have all records in the Patient Records Department, except in instances where:

1. The patient is physically present for treatment or evaluation or 2. The patient record has been requested by court order, subpoena or statute.

Additional exceptions include release of the patient record to:

1. Chiefs of Service for specific review purposes; 2. The Chief of Quality Assurance Review; and 3. The Risk Management Officer for prelitigation review

PURPOSE: To establish Guidelines for the use and/or removal of patient records from the Patient Record Department.

RESPONSIBILITY: Director of Patient Records.

PROCEDURES:

When the patient record is released under these circumstances, it is the responsibility of the individual(s) to return the patient record to the Patient Record department within 48 hours unless specific arrangements have been made with Director of Patient Records or designee. In the event that the patient record is needed for patient care, the patient record must be returned immediately upon request to the Patient Record Department. Any patient record that is taken out of the department must be signed out. (to the requestor(s) use of Chart Tracking System).

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Safeguards of Records and Computerized Data from Damage, Loss or Tampering.
POLICY: Records and Computer Systems shall be safeguarded at all times against damage, loss or tampering. This policy shall be reviewed and updated when deemed necessary.

PURPOSE: To ensure that appropriate and immediate action is taken in the event of damage, loss or tampering.

RESPONSIBILITY: Patient Records Department, Risk Management, Safety Department, Security Department.

PROCEDURE: Prevention is the key in safeguarding records from damage, loss or tampering in the event of a disaster. These steps shall be taken in such instances:

PREVENTION

Managers shall routinely check records department work areas to ensure that there are no signs of water seepage or dripping from pipes. In case of repairs, notify the respective department by telephone and fill out a work order form.

STOLEN AND LOSS RECORDS

Inform the Area Manager immediately. Contact Administration immediately. Notify the Security Department and follow up with a written report. Fill out an occurrence report and submit to Risk Management Office.

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TAMPERING

Inform the Area Manager immediately. Contact Administration immediately. Follow policies and procedures on Patient Confidentiality. Inform the Risk Management Office and follow up with a written occurrence report.

FLOOD

Contact the Facilities Department. The Administrator on duty shall contact the Associate Dean for Clinical Affairs, Director of the Patient Records Department or Director of Clinical Operations. Conduct an inventory of records.

Make a duplicate chart for those not completely damaged. Make a notation in the duplicate record for future reference. Advise the Risk Management and Safety Departments and follow up with a written occurrence report. Use the freeze-drying method to dry the wet records to prevent mold growth within 48 hours to 72 hours. (prior approval is required by Administration) Attempt to photocopy freeze-dried legible records. Create a new chart for the copies and make a notation in the chart for future reference.

FIRE

Follow fire and safety procedures.

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The Administrator on duty shall contact the Associate Dean for Clinical Affairs, Director of Patient Records or Director of Clinical Operations. Conduct an inventory of records. Make a duplicate chart for those for those not completely damaged. Make a notation in the record for future reference. Advise the Risk Management and Safety Departments and follow up with a written occurrence report.

COMPUTER SYSTEM SAFEGUARDS

In order to secure the data stored in computer systems, each user is assigned a unique log-in ID and password. Additional security is in place to prevent unauthorized use of specific functions and features of the systems located in the Records Room. The Clinical Information System is backed up daily.

QSI ( Shared Clinical and Patient Information System). PC ( Management Data Base).

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Color Coding of Patient Record Folders
POLICY: The patient record folders shall be standardized with color-coded stickers, which identify the numeral digits of the dental record number. Patient records are filed by straight numerical digit in all the Patient Record Department file areas.

PURPOSE: To aid in prevention of misfiles and in location of misfiled records. The color-coding creates distinct patterns of color in various sections of the file. A break in the color pattern in a file section signals a misfiled record.

RESPONSIBILITY: Patient Record Staff

PROCEDURE:

1. Pull blank folder(s), use the correct color label number for the first four digits and write the fifth and sixth digit. 2. Fasten appropriate dividers into the folder 3. Write the name and dental record number on the folder.

RETRIEVAL OR FILING (SEE FILING AND RETRIEVAL POLICIES)

1. Search for the primary digits i.e., the first four- (4) numbers on the chart. 2. Go to the section or zone of the file, which displays the primary digits needed. 3. Match the secondary digits needed with the primary section, then the tertiary digits.

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Arrangement of Patient Record
POLICY: To ensure that all forms are correctly filed in the patient record.

PURPOSE: To provide guidelines regarding standard chart order.

RESPONSBILITY: Patient Record and Module Staff

All outpatient materials listed below are to be filed in chronological order by date with the latest date at the top.

a. Med Hx/Consent/Registration (gray) Consent form Bill of Rights and Patient Responsibilities Medical History Initial Triage assessment Form Tobacco Assessment

b. Treatment Plan (purple) Treatment plans

c. Comprehensive Care (pink) (Primary care i.e. Comprehensive care, Pediatrics, Prosthodontics) Continuation sheets in chronologic order

d. Referral (white)

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Referral form Emergency evaluation and referral

e. Oral Surgery (red) Dental and Oral surgery form Oral and Maxillofacial Surgery clinic form. (Consultation Name) Oral and Maxillofacial Surgery clinic form Procedure/Emergency Note Informed Consent for Surgical operation. Anesthesia Record Record for Conscious Sedation Medical Clearance Continuation Sheets

f. PG Periodontics (green) Periodontics form Continuation sheets

g. PG Endodontics (orange) Endodontic Evaluation and Treatment

h. TMD (yellow) Continuation sheets

i.

Smoking Cessation (brown) Continuation sheets

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j. Correspondence (blue) Written requests received for photocopy of record Other correspondence related to patient care.

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Retrieval of Patient Records
POLICY: The Patient Record Department shall provide patient records for patients being treated in the various clinic care areas.

PURPOSE: To provide guidelines for patient record retrieval.

RESPONSIBILITY: Patient Record Department Staff.

PROCEDURE:

1. The daily schedule that contains all scheduled appointments is generated by the Clinic Information system. (QSI)

2. The daily schedule is sorted in the following order: a. Doctor name/number b. Numerical sequence c. Clinical name

3. The daily schedule is separated by clinics depending on the available staffing.

4. The day before the appointment, the staff is to take their assigned clinical requests and search for the records in the record room.

5. If a chart is located, it is pulled and checked off with on the daily schedule.

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6. All records found are separated into batches with the daily schedules for the corresponding doctors and clinics.

7. All records pulled are checked out to the appropriate location or requestor(s) by bar code.

8. Prior to the appointment date, a designated dental clinic employee picks up the batches.

9. If a chart is not located, the staff conducts a thorough search. Check for misfiles.

10. Once the record is eventually retrieved, it is sent to the respective clinic(s).

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Filing of Loose Forms
POLICY: The Patient Records Department staff shall file all loose papers generated during patient care in the proper section of the patient record.

PURPOSE: To ensure the completion of patient records.

RESPONSIBILITY: Patient Record Department Staff

PROCEDURE:

1. All loose forms shall be sent to the record room for filing.

2. Loose papers / x-rays shall be sorted out in numerical sequence for filing.

3. Forms or x-rays with no names or dental record number shall be checked for proper identification in the Clinical Information system. (QSI)

4. Forms or x-rays shall be filed in the appropriate section of the record.

5. When a chart is not found in file, the corresponding loose papers or x-rays shall be inserted into an out-guide that is labeled with the dental record number and the outguide shall be filed in its place.

6. Out-guides found in place of a chart shall be pulled after transferring the loose papers or x-rays to the chart.

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Disposal of Confidential Documents
POLICY: Copies of Xerox, carbon papers, computer generated printouts, and unwanted documents containing confidential clinical information related to any patient shall be discarded appropriately.

PURPOSE: To provide guidelines for the disposal of documents and business records containing patient information.

RESPONSIBILITY: All Employees, Students, Residents and Professional Staff.

PROCEDURE:

Shredding is the most appropriate method for disposing of confidential, clinical information.

In the event that shredding machines are not available or malfunctioning, the alternate means of discarding unwanted documents is by placing them in an authorized recycling bin located throughout the facility which in turn are shredded.

Copies of clinical documents, reports, minutes, logs, registries, computer generated reports and printouts, and/or business records may be shredded or placed in an authorized recycling bin which in turn are shredded.

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Dental Record Room Employee Training/Orientation
POLICY: The Patient Records Department shall provide training/orientation to all employees, volunteers and students assigned to the department.

PURPOSE: To ensure that every new employee receives an training/orientation on information that is necessary to perform his or her job functions while working in the Patient Records Department to ensure availability of needed records.

RESPONSIBILITY: The Director of Patient Records is responsible to orient the new employees to the department.

PROCEDURE: All newly hired patient record employees shall receive orientation, training, and education to the maintenance of dental records within two weeks of employment.

1. A checklist shall be reviewed with each employee (SEE ATTACHED LIST).

2. ensure that all health information policies and procedures are executed.

3. Upon completion of the employee orientation, a copy of the checklist shall be given to the employee and the original filed in his or her personnel file.

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Subpoenaed Patient Records
POLICY: It is the policy of Columbia Health Care to obey a subpoena and produce a certified copy of the records in the designated courtroom at the proper time.

PURPOSE: To ensure that Columbia University Health Care is in compliance with subpoena regulations and to protect patient confidentiality.

PROCEDURE: A subpoena shall be served personally by any person not a party to the action who is 18 years or older.

There are two kinds of subpoenas:

1. The witness subpoena (also called a subpoena ad testificandum) which is a document requiring the attendance of a specific person to give testimony. 2. The subpoena duces tecum, which requires (as to hospital records) merely the production of the records. It must describe what is to be produced precisely; the description must be sufficient to enable the party served to identify them without any prolonged or extensive search. In a valid witness subpoena, that person named and served must appear in court at the place and time appointed. 3. A subpoena duces tecum, which requires the production of the records must be accompanied with the patient’s authorization. 4. A subpoena duces tecum without the patient’s authorization shall be returned to the attorney who served it. 5. The Columbia University College of Dental Medicine shall only obey a subpoena that is accompanied with the patient’s authorization.

There are upwards of 141 statues giving subpoena power to different state departments, agencies, commissions, boards and public officers including:

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Board of Dental Examiners Board of Examiners of Psychologists Board of Medical Examiners Board of Pharmacy Board of Regents Board of Podiatry Examiners Board of Water Pollution Control Commissioner of Education Commissioner and Board of Visitors of Department of Mental Hygiene Commissioner of Social Services Committee on Physio-Therapy Services Director of Institutions Local Board of Health

Regents Committee on Grievances State Board of Examiners for Nurses State Board of Social Welfare State Health Commissioner Workmen’s Compensation Board and Members

The subpoena must be served at least 72 hours before the time fixed for the production of the records, unless otherwise ordered by the court. Delivery is made to the clerk of the court in a sealed enveloped indicating the title of the action, the date for production, and the name and address of the attorney appearing on the subpoena. The clerk gives a receipt for the records and thereafter notifies the University subpoenaed when they are no longer required.

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A transcript or reproduction of dental records must be certified as correct by the Superintendent or Head of the University department, unless otherwise ordered by a court. (Section 2306 of CPLR re: a subpoena duces tecum). In others words, you always furnish a certified copy unless the court itself (shown by the signature of a justice or judge) issues the subpoena and it specifically orders the original dental record of a certain individual to be produced. (CPLR Section 2302-6). All subpoenas should always be accompanied by a delegation and certification letter (see attached).

INABILITY TO COMPLY WITH THE SUBPOENA

If dental records are unavailable because they have been destroyed, misfiled or are out being microfilmed, the administrator or the dental records practitioner should, with the assistance of counsel, prepare an affidavit to that effect and have the same submitted in person to the court. The court may accept the affidavit or may require that the facility appear by witness subpoena. Occasionally a facility has lost, destroyed or mislaid a record but prior to that time an attorney may have received a photocopy. The rule in New York State is that the original record when placed in evidence is primary evidence of its contents. A copy of the document, as well as the recollections of a witness is known as secondary evidence. With proper order of proof established, the court will usually allow introduction of the copy of the record as valid secondary evidence.

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SPECIAL PROBLEMS When a State Court other than New York’s serves a subpoena, the University should consult with its counsel about the appropriate response. Where a party to an action pending in another state wishes to examine the University records or employees, such party is required under Section 3101 (e), CPLR to apply to the Supreme Court or County Court in New York State for permission to conduct such proceedings.

Similar rules apply where a Federal Court action is involved. Ordinarily a resident of a Federal Court District in which the action is pending may only be required to attend a deposition in the county in which he works or lives. If the witness resides in a district other than where the action is pending, the Court may fix a more convenient place for the deposition.

Where a trial subpoena is served in a Federal court action, it may be served at any place within the district or if served outside the district, within a 100 miles distance from point of issuance.

If a person is served with a subpoena they may request a written deposition to be taken, but attendance may be compelled. It should be understood that even if a federal Court subpoena appears to violate the above rules, it should not be ignored. Instead, the University’s attorney should move for timely objection in pursuant of Rule 45 of the Federal Rules of Civil Procedure.

For dental record practitioners in the Metropolitan New York area: when attorney advised that out-of-state court subpoena served may be regarded as a nullity, the dental record practitioner calls the assisting attorney collect, arranges for an authorization to be sent, in addition to a fee for the handling and duplication of the full chart. The records are then mailed via certified mail, return receipt requested, to the clerk of the court.

FAILURE TO COMPLY Disobedience concerning a judicial subpoena can mean immediate penalty as a contempt of court, while that concerning a non-judicial proceeding requires the issuer to first move of a court order to compliance from that point on, the procedure is parallel in that the disobedient person may be liable for a penalty of up to $50,000, together with any provable damages. In extreme cases, the law provides for the issuance of a warrant to bring the questions or to produce books, papers and things on demand. If the recalcitrant witness is also a party to the

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action, their pendings may be stricken, meaning, effect, and automatic judgment for the other side.

TIME ALLOWANCE/ON CALL The subpoena must be served at least 24 hours before the time fixed for production of the records, unless otherwise ordered by the court. Usually the courts have designated clerks to receive medical records and to see that they are delivered to the proper trial term at the appointed time. Delivery is made to that clerk with the record in a sealed envelope and address of the attorney appearing on the subpoena. The clerk gives a receipt for the records and notifies the hospital when the records are no longer required.

SUBPOENA FEES (COURTS) (According to civil Practice law #2303-all subpoena fees are $2.00) CIVIL, SUPRENE AMERICAN ARBITRATION BOARD & WORKMEN’S COMPENSATION BOARD, CITY LIMITS N.Y.C. DISTRICT ATTORNEY’S OFFICE, NEW YORK & QUEENS N.Y.C. TRANSIT AUTHORITY, JAY STREET N.Y.C. FAMILY COURT, QUEENS, BROOKLYN, YELLOW FORM N.Y.C. CORPORATION COUNSEL, MANHATTAN & QUEENS U.S. DISTRICT COURT FEDERAL – SOUTHERN DISTRICT RICHMOND COUNTY, STATEN ISLAND NASSAU COUNTY YONKERS WESTCHESTER MINEOLA SUFFOLK COUNTY & BEYOND NASSAU, YONKERS NO FEE NO FEE NO FEE NO FEE $15.00 $15.00 $15.00 $15.00 $15.00 $15.00 $15.00 $15.00

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Confidentiality of Patient Records / Patient Information and Guidelines for the Release of Information.
POLICY: It is the policy of Columbia University College of Dental Medicine to ascertain that all University employees respect the doctrine of confidentiality and do not divulge any information relative to patient’s information from the patient records and/or other information relevant to patient’s condition or treatment. These guidelines are formulated to assist employees in promulgating this policy. Under NO circumstances should employees discuss or disclose privileged information known to them as a result of their position. The University also authorizes the transmittal, receipt and filing of facsimile information from the patient record only under certain conditions and following specific guidelines. Patient records are confidential documents maintained for the benefit of the patient, the provider and the university. They are the property of the University, the contents of which must be protected against unauthorized disclosure. They may be removed from the University’s jurisdiction and safekeeping only in accordance with court order, subpoena or statute. The treating provider and the university have the duty and responsibility to check thoroughly the credentials of the person or organization requesting access to a patient’s records and to determine which specific records are desired. A release of this information to the unauthorized persons/organizations might cause a hardship to the patient and possibly be the subject of a lawsuit.

PURPOSE: To preserve the integrity of the record and the confidentiality of the information pertaining to patients and employees. It is necessary to establish guidelines respecting to: Release of patient information Handling of HIV-related information, drug, alcohol, psychiatric information including permitted disclosures. Facsimile transmittal and receipt of patient and other health.

SCOPE: The University may be obligated to withhold information as “ confidential “ in the absence of an appropriate consent on the part of the patient or in accordance with statutory provisions. In addition, there are prevailing legal considerations that affect the use of the patient record both in and out of court and that require the advice of the Columbia University College of Dental Medicine Legal Department on measures to release or withhold information. The University seeks full and free disclosure between the patient and the provider with the

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knowledge that such information will not be given general circulation. This applies to all HIV, drug, alcohol or psychiatric information and transmittal of patient information via facsimile.

RESPONSIBILITY: All Professional Staff, Students, Residents and Employees Staff.

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DEFINITIONS:

1. NON-PRIVILEGED INFORMATION: Non-privileged information is information which may be released at the discretion of the university without written authorization of the patient. The following is considered non-privileged information: a) Complete name of patient b) Address at time of admission c) Verification of patient’s visit(s) d) Name of attending physician e) Treatment date(s) f) g) Name of relative or friend given on admission The fact that the patient was ill, and had a procedure.

2. PRIVILEGED INFORMATION: Privileged information is confidential. The following information is considered privileged: a) Name and extent of patient ‘s injury or condition b) Symptoms c) Diagnosis or treatment d) Age e) Address on discharge f) The service on which the patient was treated.

AUTHORIZATIONS: Information in possession of the university may be released only after fulfilling the applicable conditions set forth below: a) Patient Authorization: Privileged information in dental records shall be released only with a written authorization, signed and dated by the patient. The patient’s authorization signature should correspond with the patient’s signature on the chart. In order to waive his/her claim of privilege, a patient

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must give written authorization for the inspection of his/her patient record before information is released. When the requesting party mails the signed and dated authorization; the Patient Records Department may release the information. Any authorization dated six months or more prior to receipt by the university will not be accepted. The authorization form becomes a part of the patient record. There is no legal requirement that the authorization be notarized.

b) Other Authorization: In the case of a mentally deficient or incompetent patient, or the death of an adult, the executor or administrator of the estate, or the committee of the incompetent who presents proper credentials from the court, signs the waiver for the release of privileged information. If there is no such fiduciary appointed, then the next of kin may sign said waiver. A copy of the proper credentials should be incorporated in the patient record. Next of kin is fixed in category of blood relationship in the descending order as follows: 1. Surviving spouse 2. Children 3. Grandchildren 4. Father and/or Mother 5. Brother and/or sisters 6. Nephews and/or nieces

c) Minors Authorization: Minors, as defined by New York State, are individuals under the age of 18. A parent or legal guardian must authorize the release of privileged information on the record of a minor. Emancipated minors may sign for the release of their own information. An emancipated minor is any given person under the age of 18 who is living apart from his parents and makes his own living, or a minor who is married.

d) Authorization for Non-Privileged Information: No authorization is necessary to disclose non-privileged information (see definition) to persons or agencies, which have a legitimate interest in the information. This information should be released with care. Requests are ordinarily refused when such information

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could, or would, result in a problem to the patient. Non-privileged information can be released to the patient’s relatives with discretion.

REQUESTS FOR PATIENT INFORMATION:

Requests for patient information are processed as set forth below: a) Insurance Companies: Third party payers, i.e., commercial insurance companies, must present written authorization for release of patient information.

Health Care Providers may not give authorization for insurance companies to obtain patient records.

b) New York State and City Health Department: Information may be released without patient authorization to certain departments within the Health Department as delineated in the New York State Health Code Section 700.4. These departments are as follows: 1) Office of the Regional Health Director 2) Office of the Assistant Regional Health Director 3) Office of Professional Medical conduct 4) Office of Medical Examiner, coroner or funeral directors 5) Medical Assistance Program (includes Medicaid) 6) Medical Rehabilitation Program 7) Venereal Disease Department 8) Health Department Dentists 9) Workers compensation programs for billing purposes. 10) Public Health Officials State and Federal agencies charged with oversight of the health care system.

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11) Correctional Institutions, Military authorities and national Security and Intelligence agencies. 12) In defense of a malpractice claim or in response to a court or administrative order.

All other departments within the State Health Department require written authorization from the patient to permit release of information.

c) Attorneys: Request from attorney must be made in writing on the attorneys letterhead accompanied by a properly executed notarized authorization.

Health Care Providers may not give authorization for attorneys to obtain patient records.

Viewing of patient records in the Patient Records Department by attorneys is not permitted.

d) Columbia University College of Dental Medicine, predoctoral and Graduate Staff: Members of the resident and student faculty staffs may freely consult in the Patient Records Department such records as pertain to their work, unless there is a suspicion that one of these individuals wishes to consult a record for purposes not favorable to the interest of the patient or to the University. Should there be such a doubt in the mind of the Patient Record staff, access to the particular record may be refused and the matter should be referred to the Director of Patient Records for decision. If the provider requests the chart of another provider’s patient, he must be either a consultant on the case currently treating the patient.

e) Other Providers: Providers who are not on the staff of Columbia University Health Care who make inquiries concerning patients must present proper authorization from the patient. No employee is to assume that merely because the applicant is a provider, she/he has more right than a non- provider to obtain information. The University administration will, however, extend all reasonable courtesy to outside providers in this regard, keeping in mind the interests of the patient and the University. Privileged information is not to be

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given over the telephone except in cases of definite emergency. In such cases, the name and telephone number of the provider is to be taken, checked in the directory or with the telephone operator and the call then is returned.

f)

Other Hospitals: Information must be released to hospitals with the patient’s authorization if the patient is presently under treatment in that hospital.

g) Patients: See Patient Access Policy.

h) Police: Only non-privileged information may be released to the police. Specific patient data is not released without authorization of the patient unless the information is subpoenaed. Identification of the person requesting information must be established prior to the release of any information.

i)

Child Welfare Agency: Report suspected child abuse/maltreatment/neglect to Child Agency in compliance with the Child Protection Act of 1973.

j)

Subpoena: The University must obey the subpoena and produce a certified copy of the records in the designated courtroom at the proper time. With regard to subpoenas from the District Attorney’s Office Court Order, or Statute, - certification that subpoenaed records are kept in the regular course of university business will excuse employees from our institution from testifying as to the maintenance of these records. A subpoena between states cannot be honored without written authorization of the patient.

k) Research: The Administration, at its discretion and with IRB approval, permits use of the patient records for this purpose. Persons other than members of the attending staff asking this privilege must secure the authorization of Administration and the Risk Manager. If identifying information is released, patient’s authorization must also be secured.

l)

Students: Students must present a signed request and their ID card prior to being permitted to review dental records. Review of records must be confined

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to the Dental Records Department and the Director of Patient Records or designee must approve such reviews.

FEE SCHEDULE FOR COPIES OF RECORDS IS SET BY NYSDOH MANDATE AND COLUMBIA UNIVERSITY HEALTH CARE and is subject to change at anytime. FEE CASES Lawyers, employers Union, Fraternal Lodges Life Insurance Companies Liability Subpoena Fee NON-FEE CASES Physicians, Hospitals Homes for Aged, Convalescent Homes Government, Social, Religious Agencies Board of Education Worker’s Compensation and Blue Cross have special agreement with hospital Patients who request access to their records and cannot afford the fee will also be considered exempt.

GENERAL: Any situation or condition not specifically covered by the above provisions must have prior authorization from the Director of Patient Records, the Risk Manager or Columbia University.

SUBPOENAS: All subpoenas for Psychiatric patient records should be court ordered before they are honored.

RELEASE OF DRUG AND ALCOHOL ABUSE RECORDS: Patient records that contain information about alcohol or drug; are protected by Federal Law (42CFR). A special release that makes the patient aware of the nature of the patient information contained in the record must be obtained before this information may be released.

RELEASE OF HIV INFORMATION: Patient records that make reference to HIV information are afforded special confidentiality protections as mandated by State Law. With the exceptions of

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those exceptions specified by law, the patient must sign a special consent before this information can be released.

Under New York State Public Health Law, HIV-related information is confidential and may only be given: a) To a patient (or to the person authorized by law who consented to the test for the patient). b) To anyone whom the patient has specifically authored to receive such information by signing a written release. c) To a health care facility (such as a hospital, blood bank, or clinical laboratory, etc.) or a health care provider (such as physician, nurse, or mental health counselor, etc.) providing care to the patient or his/her child, or anyone working for such a facility or provider who reasonably needs the information to supervise, monitor or administer a health service. d) To a sharing sex partner who the patient’s doctor believes is at significant risk for HIV infection, if the patient does not notify that person after being counseled to do so. e) To a committee or organization responsible for reviewing or monitoring a health facility. f) To a federal, state, county, or local health officer when state of federal law requires disclosure.

g) To a government agency, when the agency needs the information to supervise, monitor or administer a health or social service. h) To an authorized foster care or adoption agency. i) To insurance companies and other third party payers such as Medicaid if necessary for the payment of services for the patient. To any person to whom a court orders disclosure under limited circumstances set forth by law. Except in an emergency situation, advance notice and an opportunity to oppose the release for such information would be given the patient and the custodian of the record.

j)

k) To the Division of Parole, the Division of Probation, the Commissioner of Correction, or a medical director of a local correction facility, as permitted by HIV confidentiality regulations of such organizations.

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Other circumstances under which HIV-related information can be disclosed are:

GOVERNMENT MONITORED PROGRAMS: HIV-related information may also be provided to an authorized employee or agent of a provider or government agency when reasonably necessary for the supervision, monitoring, administration, or provision of services to a protected individual who is receiving those services under a program that is supervised, monitored, or administered by a federal, state, or local government. Regulations governing this type of permitted disclosure will be promulgated by the NYS Department of Health.

FITNESS TO ATTEND SCHOOL: A provider is permitted to disclose HIV-related information to state, county or local health officer for the purpose of reviewing the patient history of a child to determine his or her fitness to attend school, provided the consent of the parent or guardian has been obtained.

TO PROVIDE TIMELY TREATMENT: A provider may also disclose HIV-related information to a person (known to the provider) authorized pursuant to law to consent to health care for the individual when the provider reasonably believes: 1) Disclosure is medically necessary to provide timely care and treatment: and 2) After appropriate counseling as the need for disclosure, the protected individual will not inform the person.

However, the provider may not make the disclosure if the provider believes that the disclosure would not be in the best interests of the protected individual or the protected individual is authorized pursuant to law to consent to such care and treatment. Any decision or action by the provider under this provision must be recorded in the protected individual’s patient record. In many cases this exception will be invoked in cases where a minor with capacity has consented to the performance of an HIV test and the provider believes it is necessary to inform the parent or parents and the minor will not do so. The statute however, does not require disclosure to the parents if the provider believes it is not in the minor’s best interest.

OTHER GUIDELINES RELATED TO HIV:

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The Patient Records Department shall ascertain that all records that contain HIV-related information are safeguarded and maintained securely.

The Patient Records Department will also ensure that any other release of HIV- related information by the following statement: “This information has been disclosed to you form confidential records which are protected State law. State law prohibits you from making any further disclosure of the information without the specific written consent of the person to whom it pertains, or as otherwise permitted by law. Any unauthorized further disclosure in violating of State law may result in a jail sentence or both. A general authorization for the release of medical or other information is NOT sufficient authorization for further disclosure.”

RELEASE OF INFORMATION: Patient information will be released as required by State law. Additional information will be released from the record of patients containing HIV-related information only with the informed written consent, including at least the following (See Attachment HIV-Consent Form approved by the State Department of Health – Attachment III). Name of individual or institution that is to release the information. Name of individual or institution that is to receive the information. Patient’s full name, address and date of birth. Purpose or need for information. Extent of nature of information to be released. Specific dates, event, or condition upon which authorization will expire. Date that consent is signed. Signature of patient or legal representative.

EMPLOYEE RESPONSIBILITY: All health care personnel who generate, use, process or otherwise deal with patient-specific information shall uphold the patient’s right to privacy and abide with Public Health Law 27-F. Employees of the Patient Record unit are to review all patient records prior to release of health information. If HIV-related information is indicated on the record and proper authorization has not been obtained, they are not to release any information until such authorization has been received and properly filled out.

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HIV-related information is any information indicating that a person had an HIV-related test, or has HIV infection, HIV-related illness or AIDS, or any information, which could indicate that a person has been potentially exposed to HIV.

If a record containing HIV-related information is subpoenaed, the responsible employee will request the attorney, directly or through a Court Judge, to obtain a proper authorization from the patient or legal representative. A subpoena duces tecum will not be acceptable to release the patient record to a court hearing. The subpoena must be “so ordered” by a judge.

TRANSMITTAL OF PATIENT INFORMATION: See Policy.

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Schedule of Fees for Processing Request for Patient Information
POLICY: Fees will be charged for processing a request for patient information as established.

PURPOSE: To comply with written requests for the reproduction of a patient record. A reasonable fee shall be charged to the requestor. Columbia University College of Dental Medicine sets the processing costs fee schedule.

RESPOSIBILITY: Patient Records Department, Business office

FEE-CASES:

Lawyers, Employers, Union, Fraternal Lodges, Life Insurance Companies, Liability cases, Subpoenas fee, and Insurance Dental forms for disability

NON-FEE CASES:

Physicians, Hospitals, Home for Aged, Convalescent Homes, Government, Social Religious agencies, Board, of Education and Patient Access (when applicable see Patient Access Policy).

FEES:

a. The following fees shall be charged for the services indicated:

Insurance Company Photocopy of record Dental Insurance Forms

= = =

$1.50 per page $0.75 per page $6.00 - $12.50

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X-rays duplication

=

$15.00

SPECIAL PROVISIONS FOR INDIGENT PATIENTS:

a. Waivers

Fees should be waived for Medicaid/Medicare recipients who request access to their patient record and claim inability to pay the standard fee.

b. Reduced Fees

(1) A flat fee of $10.00 shall be charged for all other indigent patients who request access to their patient record and claim inability to pay the standard fee. (2) If an indigent patient claims that he or she cannot afford the $10.00 flat rate fee, then the patient should be asked to pay whatever he or she can afford. (3) Any patient shall not be denied access to a copy of his/her medical record because of his/her ability to pay

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Patient Record Requisition.
POLICY : The Patient Records Department shall provide patient records for both patient care and non-clinical purposes to authorized users upon request .

PURPOSE : To provide guidelines on patient records request to ensure safeguard, prevention of loss, mishandling, control and confidentiality of patient records.

RESPONSIBILITY : Patient Records Department, Staff, Residents, Students and Professional Staff.

GENERAL GUIDELINES FOR RECORD REQUEST :

1. Patient records needed for patient care, audit, research, etc., may be requested from the patient Record Room, 5 days a week during business hours.

2. Requests for patient records shall be addressed to the Patient Records File Room by telephone or submission of a written request.

3. Using the appropriate requisition, the individual shall complete a request for records.

4. A designated record employee shall be given the requisition to retrieve the record(s).

5. Records shall be retrieved in a timely fashion.

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6. Records pulled shall be checked to ensure their accurate identification and satisfactory condition.

7. Only authorized personnel who display appropriate University identification shall pick up the chart(s).

8. Records shall only be released and scanned to providers who have privileges at Columbia University College of Dental Medicine.

9. Retrieved records are checked out by bar code to a location or requestor using the Chart Tracking System.

10. Authorized personnel shall sign upon receipt of chart if the Chart Tracking System is down.

11. An activity record log shall be maintained of all patient records requested and pulled on a daily basis.

12. Records requested from the record room must be returned within 48 hours. If additional time is required, the file room staff should be notified and the appropriate steps taken.

13. Out-guides with requisitions shall be used when records are removed from the Patient Records File Room, if the Chart Tracking System is down

14. Records shall not be transferred from one person to another or from one clinic area to another without the Patient Records Department being notified and it being entered by bar code in the chart tracking system.

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15. When making a requisition for more than five charts, it should be submitted at least 48 hours in advance.

PROCEDURES :

1. Request is submitted for patient records. 2. Review the requisition and search for the records. 3. Retrieve the records from the permanent file. 4. Use a log sheet to write down all charts retrieved and forwarded to designated area or care provider using the Chart Tracking System.

5. Inform requestor when records are ready to be picked up. 6. Write a requisition for each chart pulled. The original requisition paper is attached to the outer chart cover to ensure that the chart is delivered to the correct clinic area and/or the right requestor. The copy is placed in an out-guide when the Chart Tracking System is down.

7. File the out-guide(s) in place of each chart retrieved . Out-guides are labeled with the patient name, dental record number, requestor name, clinic name and date.

8. If a chart is not available in the permanent file, notify the requestor of the chart status.

REQUEST OF PATIENT RECORDS FOR EMERGENCY VISITS/ WALK-INS.

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1. A request is made by phone or received at the “Correspondence/ Information Window”

2. If it is a phone request log the information in the log sheet. 3. A chart requisition is made out. 4. The retrieving procedures apply.

REVIEW OF PATIENT RECORDS BY STUDENTS AND FACULTY STAFF (NON EMERGENCY)

A requisition is submitted to the Record Room.

Records are reviewed in the Review Area of the file room or taken to their respective office.

Records for special studies and research are reviewed in the file room if necessary.

Records may not be removed from the clinics at anytime unless the Patient Records Department is notified.

The retrieving procedures apply.

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Confidentiality of Patient Records Containing HIV-Related Information
POLICY: It is the policy of Columbia University health Care to ascertain that all mandates of Public Health Law 27-F, relative to the handling of HIV-related information are enforced.

PURPOSE: To assure that HIV-related information is not improperly disclosed and to provide clear guidelines for the handling of HIV-related information including permitted disclosures.

SCOPE: This policy applies to all HIV-related patient information.

RESPONSIBILITY: Patient Records Department and Module Staff, Students and Faculty.

PROCEDURE:

A.

GENERAL GUIDELINES:

Information released to authorized individuals/agencies shall be strictly limited to that information required to fulfill the purpose stated on the authorization. Authorizations specifying “any and all information” or other such broadly inclusive statements shall not be honored. Release of information that is not essential to the stated purpose of the request is specifically prohibited.

Under New York State Public Health Law, HIV-related information is confidential and may only be given:

a.

To a patient (or to the person authorized by law who consented to the test for the patient).

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b.

To anyone whom the patient has specifically authorized to receive such information by signing a written release.

c.

To a health care facility ( such as a hospital, blood bank, or clinical laboratory, Etc.) or a health care provider (such as physician, nurse, or mental health counselor, etc.) providing care to the patient or his/her child, or anyone working for such a facility or provider who reasonably needs the information to supervise, monitor, or administer a health service.

d.

To a sharing sex partner who the patient’s doctor believes is at significant risk for HIV infection, if the patient does not notify that person after being counseled to do so.

e.

To a committee or organization responsible for reviewing or monitoring a health facility.

f. To a federal, state, county or local health officer when state or federal law requires disclosure.

g. To a government agency, when the agency needs the information to supervise, monitor or administer a health or social service.

h. To an authorized foster care or adoption agency.

i.

To insurance companies and other third party payors such as Medicaid if necessary for the payment of services for the patient.

j.

To any person to whom a court orders disclosure under limited circumstances set forth by law. Except in an emergency situation, advance notice and an opportunity

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to oppose the release of such information would be given the patient and the custodian of the record.

k. To the division of parole, the Division of probation, the Commissioner of Correction, or a medical director of a local correctional facility, as permitted by HIV confidentiality regulations of such organizations.

Other circumstances under which HIV-related information can be disclosed are:

Government Monitored Programs: HIV-related information may also be provided to an authorized employee or agent of a provider or government agency when reasonably necessary for the supervision, monitoring, administration, or provision of services to a protected individual who is receiving those services under a program that is supervised, monitored, or administered by a federal, state or local government. Regulations governing this type of permitted disclosure will be promulgated by the NYS Department of health.

Fitness to Attend School: A provider is permitted to disclose HIV-related information to a state, county or local health officer for the purpose of reviewing the medical history of a child to determine his or her fitness to attend school, provided the consent of the parent or guardian has been obtained.

To Provide Timely Treatment: A provider may also disclose HIV-related information to a person (known to the provider) authorized pursuant to law

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to consent to health care for the individual when the provider reasonably believes:

1. Disclosure is medically necessary to provide timely care and treatment; and 2. After appropriate counseling as to the need for disclosure, the protected individual will not inform the person.

However, the provider may not make the disclosure if the provider believes that the disclosure would not be in the best interests of the protected individual or the protected individual is authorized pursuant to law to consent to such care and treatment . Any decision or action by the provider under this provision must be recorded in the protected individual’s record. In many cases this exception will be invoked in cases where a minor with capacity has consented to the performance of an HIV test and the provider believes it is necessary to inform the parent or parents and the minor will not do so. The statute however, does not require disclosure to the parents if the provider believes it is not in the minor’s best interest.

B.

OTHER GUIDELINES

The Patient Record Department shall ascertain that all records that contain HIV-related information are safeguarded and maintained securely.

When oral disclosure of HIV-related information is made, it must be documented on the “Oral Disclosure of Confidential HIV-Related Information Form” and forwarded to Patient Records Department, within ten (10) days of oral disclosure. See Attachment I. The Patient Records Department utilizing the above form, will then forward a letter to the hospital, agency or individual who received said information indicating that re-disclosure is prohibited . See Attachment II.

Both the form and the letter will be filed in the patient’s record.

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The Patient Records Department will also ascertain that any other release of HIV- related information other than oral disclosure will be accompanied by the following statement:

“REDISCLOSURE OF THIS INFORMATION WITHOUT THE SPECIFIC WRITTEN CONSENT OF THE PATIENT OR LEGAL REPRESENTATIVE IS PROHIBITED. GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IS NOT SUFFICIENT AUTHORIZATION FOR FURTHER DISCLOSURE”

Release of Information: Patient information will be released as required by State law. Additional information will be released from the records of patients containing HIV-related information only with the informed written consent, including at least the following:(See Attachment HIV-Consent Form approved by the State Department of the Health.--Attachment III).

-

Name of individual or institution that is to release the information. Patient’s full name, address and date of birth. Purpose or need for information. Extent of nature of information to be released. Specific dates, event, or condition upon which authorization will expire. Date that consent is signed. Signature of patient or legal representative.

Employee Responsibility : All health care personnel who generate, use, process or otherwise deal with patient-specific information shall uphold the patient’s right to privacy.

Employees of the Patient Records Department are to review all patient records prior to release of health information. If HIV-related information is indicated on the record and proper authorization has not been obtained , they are not to release any information until such authorization has been received and properly filled out.

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HIV-related information is any information indicating that a person had an HIV-related test, or HIV infection, HIV-related illness or AIDS, or any information which could indicate that a person has been potentially exposed to HIV.

If a record containing HIV-related information is subpoenaed, the responsible employee will request the attorney directly or through a Court Judge to obtain proper authorization from the patient or legal representative. A subpoena duces tecum will not be acceptable to release the patient record to a court hearing. The subpoena must be “so ordered” by a judge and accompanied with the patient authorization.

All Other Employees All other employees who generate , use, process or otherwise deal with patient-specific information shall also uphold the patient’s right to privacy and abide with Public Health Law 27-F.

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Dental Record Completion
POLICY: All dental records shall be completed and returned in a timely fashion.

PURPOSE:

To insure that all records are completed by the provider and up to date with the treatment rendered.

PROCEDURE:

1. All entries and procedures shall be dated and documented in the record in black or blue ink.

2. All forms in the record must be labeled with the patient name and chart number.

3. The record shall be complete, legible and signed by student and countersigned by the supervising faculty.

4. Upon completion of the record, it shall be returned to the patient record department within 48 hours.

5. Under no circumstances shall the record be stored any where other than in the record room.

6. Charts found in other areas will lead to loss of clinical privileges.

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Filing of Patient Records.
POLICY: The Patient Records Department staff shall file all retrieved patient records daily.

PURPOSE: To provide guidelines for filing patient records in a timely and efficient manner.

RESPONSIBILITY: Patient Records Department and Module Staff

PROCEDURE

1. Records shall be returned by a designated employee or provider to the record file room, upon discharge of patients.

2. Records received shall be checked in the record room using the bar code Chart Tracking System.

3. Records shall be sorted into numerical sequence.

4. Records shall be filed in their appropriate zones.

5. The Patient Record Director shall be notified of all records that are not received from the clinics on a daily basis.

6. The Patient Record Director shall inform the Clinic Managers or designee or chief of services of the missing records.

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7. The Clinic Managers and chief of services shall take appropriate action to obtain the records and forward them to the record file room.

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Health Information Forms
POLICY: According to all Health Care Information Policies, all Faculty, Students and staff must use the appropriate forms in Health Information Management.

PURPOSE:

To ensure proper and compliant use of patient information and records.

PROCEDURE:

The following forms listed below and attached have been approved and must be used according to the Health Information Policies of Columbia University College of Dental Medicine Clinics.

Statue of Limitations Purging Control Sheet Facsimile Cover Sheet Patient Record Activity Log Delegation of Authority Confidentiality Statement Confidentiality Statement for Staff Confidentiality Disclosure Statement Certification Invoice Letter Authorization to Disclose Patient Information

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Informed Consent
POLICY: All patients must be informed of risks, benefits, and the prognosis of the treatment to be rendered and to consent in writing to its being performed prior to initiation of such treatment.

PURPOSE:

For all patients to understand and consent in writing to their care.

PROCEDURE:

1. All patients shall be fully informed about the proposed treatment, along with alternative treatments, in such manner that they can, with full understanding, approve or refuse treatment.

2. Patients are asked to sign that they understand the treatment to be rendered.

3. Patients sign at the time of registration to permit evaluation and diagnostic procedures necessary to properly assign them for care.

4. Patients must sign a second time after the completion of the diagnostics and a comprehensive treatment plan is discussed and explained.

5. This second signature must be accompanied by the student and the faculty member who discussed the treatment plan with the patient. This signature is on the bottom of the Treatment Plan sheet.

6. Any subsequent changes to patient’s treatment plans must be fully explained and approved by the patient before they are implemented.

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7. These changes should be documented and signed in the chart either by a signature in the continuation sheet or by the full completion of a new Treatment Plan sheet.

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Medical Alert Stickers
POLICY: All patients with positive findings in significant illness, medications and allergies must have medical alert sticker place on the inside of the record. Placed on the inside front cover.

PURPOSE:

to ensure identification of potential medical conditions that could affect dental care.

PROCEDURE:

1. All patients who register for oral health care are evaluated.

2. The medical history summary must include: Significant illness, medications and patient allergies.

3. Any patient with positive findings in the medical history summary that may alter the delivery of oral health care will have a medical alert sticker placed on the inside of the record.

4. A Medical Alert list must be placed on the inside cover and have listed reasons for the medical alert.

5. The student must obtain the sticker from the module area and place it on the front inside of the record in the upper right hand corner.

6. Patients medical history be reviewed periodically and medical alert sticker placed as needed.

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Dental Record Duplication
POLICY: Dental records may be duplicated with an appropriate request.

PURPOSE:

To duplicate records in an appropriate, expeditious way.

PROCEDURE:

1. To request duplication of dental records, a duplication request form must be filled out and signed by the patient. This request form is available at the window of the patient records department on VC-8.

2. The patient will pay according to the established fee schedule.

3. If radiographs are also requested, an additional fee will be required according to the established fee schedule.

4. Patients should be informed that 10 business days are required to duplicate the chart and radiographs.

5. The duplicate may be mailed to the patient or picked up in the patient record department.

6. Patients will not be denied a copy of their records based on their inability to pay.

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Facsimile of Patient Information
POLICY: Columbia University College of Dental Medicine authorizes the transmittal, receipt and filing of facsimile information for the patient record, only under certain conditions and following specific guidelines.

PURPOSE: The patient record serves as the official record of events and clinical services provided to patients. Maintenance of a patient record that is clear, complete, accurate and timely is critical to patient care at Columbia University College of Dental Medicine. In order to preserve the integrity of the record, and the confidentiality of the patient information contained therein, it is necessary to establish guidelines regarding facsimile transmittal, and receipt of patient and other health information.

RESPONSIBILITY: All employees, students, residents and faculty Staff.

TRANSMITTAL OF PATIENT INFORMATION

Transmittal of patient information via facsimile machine is authorized under the following circumstances:

In an emergency when clinical data to be used for patient care is requested but the original document or mail-delivered photocopies cannot be received in time.

DOCUMENTS TO BE FAXED:

The Patient Records Department will release only essential information and only in the case of a dental emergency. Each request must be limited to the specific documents requested.

PROCEDURE:

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The following procedures must be followed:

1. The Fax cover sheet with each transmission must include the following information:

a. Date and Time of fax transmission (this can also be machine generated). b. Sending facility’s name, location, telephone and facsimile numbers and authorized receiver’s name. c. Receiving facility/provider name, address, telephone, and facsimile numbers and authorized receiver’s name. d. Number of pages sent (including cover letter). e. Statement regarding re-disclosure and /or destruction. (See Attachment Form)

2. Verify via telephone, the availability of the authorized receiver before and after the transmission.

3. Request that the authorized receiver sign and return the receipt form, via fax upon receipt of faxed data. If confirmation is not received, call to verify receipt.

4. Maintain a record of the facsimile transactions (i.e. Requests, Receipts and Documents sent).

5. The original cover letter and original request must be filed with the specific printed receipt document in the correspondence section of the patient record .

CONFIDENTIALITY

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The recipient of the patient information is prohibited from disclosing the information received to any other party and is required to destroy the information after the stated need has been fulfilled

MISDIRECTED FAX:

In order to maintain patient confidentiality, attempts must be made to trace misdirected facsimile copies:

1. If a fax transmission fails to reach the recipient, attempt to determine recipient’s fax number by generating a printout from the machine’s internal logging system or other method to obtain the recipient’s fax number.

2. Fax a request using the incorrect fax number, explain the misdirected information and ask for a destruction of all documents received from Columbia University College of Dental Medicine.

3. Maintain a record of all misdirected information and attempt to rectify.

THE FOLLOWING PROCEDURE IS TO BE FOLLOWED FOR RECEIPT OF PATIENT INFORMATION VIA FAX:

1. Remove any transmitted facsimile information immediately from the facsimile machine to avoid breach of confidentiality.

2. Match the documents received, against number of pages sent, as per cover sheet of sender.

3. Notify sender immediately if any pages are missing.

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4. Follow any instructions on the cover sheet regarding redisclosure and/or destruction.

5. Notify intended receiver immediately, if any document was received by a different individual other than the addressed party.

6. Place documents in a sealed envelope.

7. Take appropriate actions if necessary.

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Contents – Ionizing Radiation
Radiology Prescription Form ....................................................................................................... 165 Radiology Facility Compliance ..................................................................................................... 166 Institutional Obligations to the Patient ....................................................................................... 168

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Radiology Prescription Form
PURPOSE: To ensure proper documentation of all patient radiographic exposures.

POLICY:

The Radiology Request Form must be completed and signed by a licensed dentist.

PROCEDURE:

1. All patients must be examined clinically to determine which radiographic view(s) are required. The clinical examination must be documented in the progress notes.

2. The radiographic record in the patient chart must be filled in appropriately.

3. The Radiology Prescription Form must be completed and signed by a qualified dentist.

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Radiology Facility Compliance
POLICY: All Radiology facilities must meet federal, state and local regulations.

PURPOSE:

To insure that all Radiology Facilities are in compliance with federal, state, and local laws and regulations.

PROCEDURE:

1. All existing radiographic equipment and facilities shall meet all regulations specified and/or recommended by the Federal Radiation Health and Safety Act of 1969, NCRP Handbooks 35 and 145 on Dental X-ray Protection, ADA recommendations on acceptable radiographic practices, and the provisions of the NYC Health Code.

2. Radiographic facilities shall be designed to maximize student/operator/patient protection from unnecessary exposure to ionizing radiation. This includes the use of long, rectangular collimation for all periapical and bitewing exposures.

3. The fastest speed image receptor consistent with diagnostic requirements should be used.

4. Film aligning instruments shall be used for intraoral periapical and bitewing projections whenever feasible

5. Film processing shall be monitored on a regular basis to assure film quality.

6. A quality assurance program shall be implemented.

7. The Oral Radiology clinic shall be equipped with facilities for optimal viewing of radiographs.

8. Radioprotective barrier devices, such as lead aprons and thyroid collars shall be used, as appropriate, during all radiographic exposures.

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9. X-ray film and other image receptors will be kept secure at designated dispensing areas to prevent unauthorized use.

10. No dental personnel shall be present in the room, in which a radiographic exposure is being made, except if they are being exposed as a patient for a diagnostic radiograph.

11. Proper infection control shall be observed at all times by all users of the Oral Radiology clinic.

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Institutional Obligations to the Patient
POLICY: Patients will be exposed to radiographs only for the necessity of diagnostic patient evaluation.

PURPOSE:

To insure that all patients are exposed to the minimal amount of radiation.

PROCEDURE:

1. All radiographs are prescribed according to the document “Guidelines for Prescribing Dental Radiographs” which can be accessed using this link: http://www.ada.org/prof/resources/topics/topics_radiography_chart.pdf

2. Patients shall not be subjected to radiographic screening examinations

3. Copies of radiographs shall be made available to private practitioners or other appropriate professionals upon request of the patient. A small administrative fee may be charged, as appropriate.

4. The prescribing doctor shall assess the possibility of fetal irradiation in women of childbearing age.

5. Radiographs shall not be taken for the exclusive purpose of satisfying requirements of Dental Examining Boards.

6. Patients shall not be subjected to retakes to satisfy technical perfection rather than clinical acceptability.

7. Reasonable effort should be made to identify and obtain (from outside practitioners) recent and pertinent prior radiographs of new patients.

8. A record of the radiographs, retakes, and all exposure factors shall be recorded on the designated space and relevant radiographic findings shall be recorded in the chart.

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9. Radiographs must be processed immediately.

10. Radiographs must be mounted, and properly identified with patient's name, chart number and date of examination.

11. Radiographs must be approved for diagnostic quality by a faculty member. 12. Faculty authorization is required for any retakes. Retakes must be exposed under supervision.

13. Radiographs shall be interpreted only under appropriate optimal conditions.

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