Table of Contents

November 5, 2007

APPROVED ADMINISTRATIVE DIRECTIVES

100 ADMINISTRATIVE
200 COMMITTEES
300 EMERGENCIES
400 THERAPY SERVICES
500 MEDICAL-NURSING SERVICES
600 SUPPORTIVE
700 HOSPITAL OPERATIONS
800 SECURITY
900 HUMAN RESOURCES

CSH Nursing Procedures
Administrative Section
Coalinga State Hospital Nursing Policy and Procedures Manual

Section 1-Admissions
Section 2-Abbreviations
Section 3-Nursing Care
Section 4-Treatments
Section 5-Medications
Section 6-Diagnostics
Section 7-Emergency Procedures
Section 8-Infection Control
Section 9-Clothing & Linen
Section 10-Central Supply
Section 11-Orientation
Section 12-In & Outside Facility Consultations
Section 13-Psych Nursing Interventions


100 – ADMINISTRATIVE

November 5, 2007

101-administrative-directives-12-07-06.pdf106-administrative-directives-reading-and-filing-procedures.pdf

110-governing-body-coalinga-state-hospital-10-5-06.pdf

114-executive-director-10-5-06.pdf

118-medical-director-1-11-07.pdf

122-hospital-administrator-6-14-07.pdf

126-clinical-administrator-11-9-06.pdf

130-facility-declaration-8-10-06.pdf

134-facility-plan-for-services-6-14-07.pdf

136-residential-recovery-units-10-5-06.pdf

138-performance-improvement-program-11-9-06.pdf

142-compliance-plan-medicare-part-b-6-14-07.pdf

146-administrative-rules-9-07-06.pdf

150-relationship-security-safe-therapeutic-interactions-12.pdf

154-public-relations-2-16-07.pdf

158-administrative-services-10-5-06.pdf

162-executive-officer-of-the-day-eod-3-22-07.pdf

166-risk-management-documental-reporting-02-15-07.pdf

170-program-administration-11-9-06.pdf

174-hospital-advisory-board-1-19-07.pdf

178-organizational-ethics-11-9-06.pdf

182-sentinel-events-2-14-07.pdf


200 – Committees

November 5, 2007

202-hospital-committees-9-7-06.pdf206-medical-staff-committees-1-11-07.pdf

210-research-human-subjects-committee-1-19-07.pdf

214-administrative-directive-review-process-1-19-07.pdf

218-patient-care-policy-committee-7-12-07.pdf

222-special-purpose-trust-accounts-audit-committee-11-9-06.pdf

226-hospital-emergency-preparedness-committee-10-5-06.pdf

230-contraband-technology-transfer-committee-8-10-2006.pdf

234-hospital-forms-management-committee-9-7-06.pdf

238-patient-benefit-fund-committee-12-7-06.pdf

242-movie-committee-10-05-06.pdf

250-account-managers-committee-10-5-06.pdf

254-documentation-system-ds-committee-7-12-07.pdf

258-property-survey-committee-11-9-06.pdf258-property-survey-committee-11-9-06.pdf

262-nursing-policy-procedure-committee-11-9-06.pdf

266-resource-management-committee-9-7-06.pdf

274-joint-labor-management-committee-11-9-06.pdf

278-protected-health-information-committee-6-14-07.pdf

282-hospital-standing-committees-11-9-06.pdf


300 EMERGENCIES

November 5, 2007

302-individual-escape-and-notification-policy-7-12-07.pdf

306-life-safety-management-program-02-08-07.pdf

310-fire-plan-procedures-in-case-of-6-14-07.pdf

314-fire-plan-fire-exit-drill-and-evacuation-drill-procedu.pdf

322-fire-plan-exit-information-for-southern-steal-exit-doo.pdf

326-fire-inspections-5-10-07.pdf

330-alarm-system-9-7-06.pdf

334-emergency-preparedness-program-10-5-06.pdf

338-organization-of-emergency-response.pdf

342-first-aid-emergency-services-plan-7-12-07.pdf

343-emergency-services-plan-life-threatening-emergency3.pdf

346-outside-medical-treatment-2-16-07.pdf

350-withholding-or-withdrawal-of-life-sustaining-services-02.pdf350-withholding-or-withdrawal-of-life-sustaining-services-02.pdf

354-organ-tissue-donation-02-14-07.pdf

358-outside-emergency-laboratory-services-5-10-07.pdf

362-hazard-communication-program-6-14-07.pdf

366-hazardous-materials-waste-management-program-6-14-07.pdf

370-emergency-services-plan-7-12-07.pdf


400 THERAPY SERVICES

November 5, 2007

402-security-escape-risk-assessment-9-7-06.pdf

406-polygraphs-11-9-06.pdf

408-by-choice-incentive-system-2-16-07.pdf

410-hospital-wide-patient-advisory-council-1-19-07.pdf

414-research-12-7-06.pdf

418-audio-or-visual-recording-procedures-7-2-07.pdf

422-psychology-department-8-10-06.pdf

426-rehabilitation-therapy-and-activity-service-7-12-07.pdf

430-department-of-social-work-11-9-06.pdf

434-active-treatment-interventions-2-14-07.pdf

438-clinical-outcome-evaluation-system-04-13-06.pdf

442-placement-of-limited-english-speaking-patients-1-19-07.pdf

446-wellness-recovery-planning-8-10-06.pdf


500 MEDICAL-NURSING SERVICES

November 5, 2007

504-admission-suite-6-14-07.pdf

508-infection-control-program-10-5-06.pdf

510-personal-relationships-sexuality-5-10-07.pdf

512-patient-medical-and-psychiatric-examinations-02-14-07.pdf

516-wellness-recovery-team-1-18-07.pdf

518-nursing-services-2-16-07.pdf

520-nurse-of-the-day-nod-2-16-07.pdf

522-individual-release-7-12-07.pdf

524-intra-hospital-transfer-of-individuals-6-14-07.pdf

526-suicide-prevention-12-7-06.pdf

528-patient-death-3-8-07.pdf

530-compassionate-leave-for-terminal-illness-funerals-3-8-07.pdf

532-pharmaceutical-services-5-10-07.pdf

534-pharmaceutical-representatives-visits-12-7-06.pdf

538-medication-treatment-procedure-orders-7-13-06.pdf

540-procedure-for-involuntary-psychotropic-medication-2684-3.pdf

542-procedure-for-involuntary-psychotropic-medication-6600-3.pdf

546-procedure-for-authorizing-involuntary-medical-treatment.pdf

548-screening-for-possible-movement-disorders-related-to.pdf

550-medical-officer-on-call-moc-pmoc-5-10-07.pdf

552-restraint-and-or-seclusion-3-8-07.pdf

554-prevention-management-of-assaultive-incidents3-8-07.pdf

556-search-policy-and-procedurers-12-7-06.pdf

558-patient-access-system-04-13-06.pdf

560-outside-consultants-therapists-hospital-clinic-facili.pdf

564-advance-directives-3-8-07.pdf

566-pain-management-7-12-07.pdf

568-nursing-staff-allocation-minimum-on-duty-coverage-2-16.pdf

570-overtime-for-nursing-staff-2-16-07.pdf

580-patient-medical-records2-14-07.pdf

581-hipaa-patients-access-to-the-medical-record-10-5-06.pdf

583-hipaa-protected-health-info-use-and-disclosure-rules-5-1.pdf

584-hipaa-health-information-privacy-security-3-8-07.pdf

585-hipaa-protected-health-informatio-amendment-or-correctio.pdf

586-medical-record-charts-10-5-06.pdf

587-health-information-privacy-complaint-3-8-07.pdf

590-documentation-standards-5-10-07.pdf

591-abbreviations-7-12-07.pdf

592-midnight-census-report-5-10-07.pdf

594-transfer-criteria-to-the-acute-medical-psychiatric-unit.pdf

596-transfer-criteria-icf-units-to-rrus-11-9-06.pdf

598-refusal-of-services-7-12-07.pdf


600 SUPPORTIVE

November 5, 2007

602-union-square-grill-and-canteen-6-14-07.pdf

604-patients-rights-advocacy-program-6-14-07.pdf

606-complaint-procedure-individuals-7-12-07.pdf

608-individuals-access-to-the-courts-7-12-07.pdf

610-procedure-for-documentation-of-denial-of-rights-6-14-07.pdf

612-patients-rights-treatment-related-issues-7-12-07.pdf

614-patient-admissions-and-reception-5-10-07.pdf

616-dental-services-6-14-07.pdf

618-marriage-of-individuals-4-12-07.pdf

620-off-unit-individual-movement-1-19-07.pdf

624-individuals-mail-and-packages-4-12-07.pdf

626-individuals-property-and-storage-1-19-07.pdf

628-meal-allowance-2-14-07.pdf

630-therapeutic-diets-nourishments-ordering-service-4.pdf

632-ancillary-dietetic-activities-4-17-07.pdf

638-hospital-wide-events-involving-individuals-5-10-07.pdf

640-hospital-religious-practices-6-14-07.pdf

642-native-american-spiritual-items-4-13-07.pdf

644-trust-office-functions-5-10-07.pdf

646-central-medical-services-6-14-07.pdf

648-entertainment-4-16-07.pdf

650-patient-voter-registration-4-12-07.pdf

651-processing-of-departmental-and-united-states-postal-serv.pdf

652-overtime-meal-tickets-allowance-6-14-07.pdf

654-individual-personal-computers-11-9-06.pdf

656-medicare-part-d-10-5-06.pdf

658-individuals-use-of-electricity-and-electrical-devices-5.pdf


700 HOSPITAL OPERATIONS

November 5, 2007

702-conference-room-scheduling-1-18-07.pdf

706-smoking-regulations-12-7-06.pdf

710-vector-control-5-10-07.pdf714-maintenance-policy-7-12-07.pdf

718-motor-vehicles-electric-carts-9-7-06.pdf

722-telecommunication-7-12-07.pdf

726-travel-4-12-07.pdf730-safeguarding-control-of-state-personal-property-5-10.pdf

734-transportation-of-individuals-4-16-07.pdf

738-individual-visiting-regulations-5-10-07.pdf

742-hospital-computers-8-10-06.pdf

746-internet-access-and-use-12-7-06.pdf

750-resource-management-9-7-06.pdf

754-space-allocation-furniture-and-equipment-11-9-06.pdf758-property-loss-claims-individuals-staff-and-visitors-7.pdf762-vehicle-parking-and-traffic-regulations-12-7-06.pdf

766-department-of-health-services-visits1-11-07.pdf

768-department-of-health-services-reportable-events-02-15-07.pdf

770-dmh-headquarter-reportable-events-02-16-07.pdf

772-refrigerator-freezer-monitoring-3-8-07.pdf

774-monitoring-of-water-temperatures-4-12-07.pdf

776-state-issued-personal-communication-devices-pcds-02-08.pdf


800 SECURITY

November 5, 2007

801-department-of-police-services-1-11-07.pdf

803-complaints-against-dmh-state-hospital-peace-officers-10.pdf

806-facility-security-staff-responsibility-7-2-07.pdf

810-security-sallyports-1-11-07.pdf

814-individual-counts-6-14-07.pdf

816-patients-roles-responsiblities-during-patient-counts-5.pdf

818-contraband-7-12-07.pdf

820-search-policy-and-procedures-4-25-07.pdf

822-photo-identification-cards-11-9-06.pdf

830-special-incident-reports-02-14-07.pdf

834-photographs-and-special-examinations-of-patient-injury-1.pdf

835-dna-sample-collection-requirements-6-14-07.pdf

836-registration-requirements-for-sexarsonnarcotics-offend.pdf

838-unit-security-2-16-07.pdf

842-individuals-dress-code-and-clothing-regulations-1-19-07.pdf

846-security-facility-access-clearances-5-10-07.pdf

850-interhospital-individual-transfers-8-10-2006.pdf

854-locking-and-unlocking-of-units-5-30-07.pdf

858-key-control-02-15-07.pdf

862-tool-control-inside-facility-3-8-07.pdf

864-administrative-isolation-7-12-07.pdf

868-law-enforcement-interventions-7-12-07.pdf

869-patient-death-investigation-procedures-10-5-06.pdf


900 HUMAN RESOURCES

November 5, 2007

900-utilization-access-to-hospital-grounds-and-employees-4-1.pdf

901-supervision-4-16-07.pdf

902-dress-personal-grooming-standards-8-10-06.pdf

903-employee-suggestions-4-16-07.pdf

904-personnel-records-use-access9-7-06.pdf

905-time-reporting-12-7-06.pdf

906-sick-leave-4-16-07.pdf

907-sexual-harrassment-4-17-07.pdf

908-alternate-work-schedule-8-10-06.pdf

909-discrimination-policy-9-07-06.pdf

910-religious-accommodation-4-17-07.pdf

911-disability-discrimination-02-8-2007.pdf

912-organization-chart-7-12-07.pdf

925-workplace-security-4-12-07.pdf

931-staff-hiring-9-7-06.pdf

932-out-of-class-working-assignments-6-14-07.pdf

934-substance-abuse-testing-of-employees12-7-06.pdf

935-occupational-health-clinic-9-7-06.pdf

936-pre-employment-and-annual-health-examinations-9-7-06.pdf

937-pre-employment-drug-testing-at-state-hospitals-1-19-07.pdf

946-training-6-14-07.pdf

947-career-development-programs-6-14-07.pdf

961-labor-relations-policy-6-14-07.pdf

976-duty-to-warn-inform-report-abuse-serious-threats-5.pdf

977-critical-incident-debriefing-11-9-06.pdf

978-accident-prevention-program-for-state-and-private-vehicl.pdf

979-hospital-health-safety-program-10-5-06.pdf

980-employee-assistance-program-7-12-07.pdf

981-limited-duty-assignments-9-7-06.pdf982-hospital-environmental-inspection-team-12-7-06.pdf

983-reporting-for-duty-performance-fitness-10-5-06.pdf

984-reasonable-accommodation-10-5-06.pdf

985-formal-employee-assistance-program-referrals-8-1-05.pdf

991-subpoenas-court-appearances-and-lawsuits-7-12-07.pdf

992-incompatible-employee-activities-11-9-06.pdf

993-hardship-salary-advance-8-10-06.pdf

994-orientation-temporary-contract-labor-6-14-07.pdf

995-licenses-certifications-verifications-7-12-07.pdf

996-employee-fitness-center-4-12-07.pdf