Effective Date: 
Wed, 03/21/2018

UCSC Student Health Services (SHS) supports professional development and continuing education (CE), internally with inservices, guest expert speakers and clinical meetings.

All licensed professionals must maintain their current licensure and keep it in good standing.  Approved and reported continuing education is a requirement for most licenses and current licensure will be checked during credentialing and recredentialing.

Paid professional development and continuing education leave is dependent upon meeting the criteria within the licensed professional's labor agreement and may include successful passing of the probationary period, satisfactory performance evaluations etc. as well as applicability to the position/job/role.  Timing of the leave will be based on operational needs. 

When possible, UCSC SHS may financially support the acquisition of CE, including travel, up to a maximum amount determined by the executive director.  The support will also be determined according to the staff role, prorated based on appointment rate and the negotiated labor agreement when applicable.

The continuing education and/or leave must be pre-approved in advance by the staff member's manager using the Education Leave Request, form HC 903.

All UCSC financial policies will be followed.



Effective Date: 
Mon, 03/19/2018

UCSC Student Health Services selects products for sale to patients.

Contracted vendors are used and all new contracts are filed with and approved by Financial Administrative Services and Transactions / Accounts Payable (FAST/AP).

The prime vendors are in Group Purchasing Organizations (GPO's) arranged with the University of California, Office of the President contracting office.


Supplies that are sold to patients are acquired from contracted providers and any new products are recommended by clinical staff and brought to clinical management for decisions to purchase.


Pharmacy prescription products must be on the contracted UC SHIP Pharmacy Benefit Manager Formulary for items to be covered.  The UCSC Pharmacy and Therapeutics Committee approves Over-the-Counter (OTC) and natural products with involvement by clinicians with expertise in specific areas.  

The Pharmacy also purchases snacks and sundries through contracted providers.


Optometry patients go through the University of California Berkeley School of Optometry list of approved suppliers and products.



Effective Date: 
Wed, 03/14/2018
Wed, 03/14/2018

The UCSC Pharmacists have privileges to furnish epinephrine auto-injectors without a prescription to first responders and trained lay rescuers for the purpose of rendering emergency care in accordance with Section 1797.197a of the Health and Safety Code per Regulation 4119.3.

Per protocol, the UCSC Pharmacists may prescribe and individually label auto-injectors if:

  • a campus community member presents a current certificate demonstrating that the person is trained and qualified under Section 1797.197a of the Health and Safety Code to administer an epinephrine auto-injector to another person in an emergency situation
  • the pharmacy follows the exact rules for labeling the auto-injectors and provides a log 

See the attached regulations and protocol

UCSC Protocol for UCSC Pharmacist Furnishing Epinephrine Auto-Injectors to First Responders or Lay Rescuers

The California State Board of Pharmacy has approved regulation 4119.3 for pharmacists to furnish, without a prescription, epinephrine to first responders and trained lay rescuers for the purpose of rendering emergency care in accordance with Section 1797.197a of the Health and Safety Code, if both of the following requirements are met.


Effective Date: 
Sat, 03/03/2018

The pharmacy will maintain inventory electronically through the pharmacy software.  All additions, subtractions and changes will be documented in the software.


Staff will add inventory electronically into the pharmacy software to include current costs.  Dispensing, clinic distribution and sales will automatically remove inventory.

Any outdates, damaged items, give aways, gift certificates or other items removed from inventory will be adjusted in the software.

Any split fills (two different generics dispensed at one time) will need to be adjusted in the software.  This is paramount with controlled substances.


Effective Date: 
Fri, 02/23/2018
Mon, 03/05/2018

All clinic supplies are monitored monthly ensuring that all supplies are within manufacturer (or other documented) expiration dates.

Expired supplies are removed from use in the clinic and returned to suppliers or disposed of as appropriate.


Effective Date: 
Fri, 02/23/2018

Directly Observed Therapy (DOT) is performed at the UCSC Student Health Center Pharmacy for treating latent tuberculosis infections (LTBI).

Arrangements can be made through SHS providers and county health departments for UCSC Pharmacists to provide the therapy and directly observe and document the treatment of LTBI.

Any problems or discrepancies in continuous treatment will be reported to the related county health department.



Effective Date: 
Thu, 02/22/2018

Per California regulations (California Health & Safety Code § 120582), it is permissible and recommended to initiate expedited partner therapy (EPT) to treat sexual partners of patients diagnosed with treatable sexually transmitted infections (chlamydia and gonorrhea) without the healthcare provider first examining the partner via Patient Delivered Partner Therapy (PDPT).

The UC SHIP Pharmacy Formulary Committee concurred and the agreed upon practice includes the following:

  • Write prescription for patient and document “For partner treatment”, to be divided into two separate fills / 2 prescriptions, with 1 prescription for student, and second prescription for partner  
    • Note: for prescription for partner - recommend checking allergies or potential side effects from medication
  • Prescription would be full price for partner - UC SHIP would cover the claim for the patient


Effective Date: 
Wed, 02/21/2018

The UCSC Student Health Center Pharmacy posts and supplies the ISMP lists for Confused Drug Names (Look-Alike / Sound-Alike) Medications and the ISMP High Alert Medications.


Effective Date: 
Thu, 02/22/2018

The UCSC Student Health Center Pharmacy follows the Clozapine REMS - Risk Evaluation and Mitigation Strategy for our patients on this high risk medication via the Clozapine REMS website.


The Pharmacy is certified and enrolled in the program and re-qualifies online at the website every two years.  The trained pharmacists filling the prescription review the laboratory tests and depending on the results, can fill the prescription.  The pharmacists process the prescription and at adjudication, will see whether the claim and REMS was successful. 

While it is not required, the pharmacists document the Predispense Authorization, or PDA on the hard copy of the prescription or refill label which is included in the claim adjudication and stored there for future reference.


Effective Date: 
Fri, 01/19/2018

Introduction and Background

Access to Protected Health Information (PHI) is on a need-to-know and minimum-necessary basis and is limited to the minimum data set required. 

Health Center staff members are given appropriate access to information systems and workstations containing PHI based on the role they serve.  Upon hire, staff members are granted access to appropriate systems and workstations during the orientation process.  An Information Systems Activation/Termination form is initiated by the supervisor and submitted to the Information Systems Coordinator where access to systems is set up based on a role-based access matrix.  The activation/termination form requires the approval of the immediate supervisor as well as account administrator (Information Systems Coordinator or Medical Records/System Administrator).  Staff members not identified as requiring access are not granted access.  The Health Center HIPAA Compliance Team reviews the SHS Role Based Access Matrix when roles are added or modified, and at least annually.

All Health Center employees, student workers, volunteers and temporary contract workers receive privacy and security training on access, use and disclosure of PHI during the initial orientation period and prior to access being granted.  The training is specific to the employee’s job functions.

All Health Center employees, student workers, volunteers and temporary contract workers are required to sign the Health Center Confidentiality Statement.

UCSC Student Health Services (SHS) conducts, at a minimum, quarterly surveillance audits of select patient charts to ensure that proper privacy and access is maintained.  The surveillance program involves a review of SHS employee access to patient charts according to specified criteria.

Philosophy and General Approach

All patients have a right to privacy.
Privacy and security safeguards and protections should not interfere with patient care.
All system users are held personally accountable for protecting patient data.
Accountability will be enforced by routine surveillance and investigation of complaints using audit trails.
Inappropriate access to patient information may result in disciplinary action up to and including termination of employment.


The following account types/scenarios may be included in the quarterly audit plan.

Special charts.  Some charts are designated as “special” within the EMR (including employees and student employees).
VIP accounts.  Any known accounts of university administrators or VIP parents (i.e. child of university official, child of public figure or celebrity).
Patients in the news.  Stories in the news that involve a UCSC student which may prompt a staff member to look in the EMR (i.e. student accident)
Patient deaths. - Sequestered
Employee charts. - (See Special Charts above)


Student Health Services has established a surveillance audit team consisting of the Medical Director, Clinic Director, Business and Information Systems Coordinator, and Medical Records System Administrator.

Each quarter, the team establishes a surveillance audit plan that includes reviewing at least ten (10) patient charts falling under the above criteria.  Patient access reports are run out of the Electronic Medical Record (EMR) system for the designated time period and are then reviewed by the surveillance team.  The review may include a review of the patient chart including the history of the particular appointment(s) and/or visit(s) to determine whether access was necessary and appropriate.

Any access that is suspected of being unnecessary or inappropriate is documented in the RL Solutions incident reporting system where it is assigned to the direct supervisor of the staff member for further investigation.  The investigation may include interviewing the staff member to gather more information regarding the access.  Access deemed unnecessary or inappropriate will result in disciplinary action according to established HR procedures.  

A final audit summary is produced annually by the surveillance team, is reported to the QM committee, and the audit plan, access reports, and summary are filed and/or saved electronically.  Any employee disciplinary actions are documented in either the supervisor’s employee file (i.e. counseling memo) or the official employee file (i.e. letter of warning or termination).

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