Main

H.2.

The organization obtains written informed consent from the patient or the patient’s representative before the procedure or surgery is performed. 

H.1.

There is documentation that the necessity or appropriateness of the proposed procedure or surgery, as well as alternative treatment techniques, have been discussed with the patient. 

F.

Electronic data management is continually assessed as a tool for facilitating the Standards above. 

Q.

High level disinfection processes adhere to equipment and chemical manufacturers’ instructions. 

I.H.

At a minimum, all settings where sedation or anesthesia is administered should have the following equipment for resuscitation purposes:

I.Q.

A written policy outlines appropriate hand hygiene using products according to the product manufacturer’s instructions for use 

Location: 
P&P
Policy: 

I.B.02

Based on nationally-recognized infection prevention and control guidelines considered and selected by the governing body. 

III.C.

In solo physician or dental organizations, an outside physician or dentist is involved to provide peer-based review. 

II.B.5.b

Upon reciept of a completed reappointment application, the organization will conduct primary or secondary source verfication items listed in Standards 2.II.B.3.c-f.  At the time of reappointment consideration by the governing body, the entire reappointment application and the peer review activities and results, completed in accordance with Chapter 2.III, will be considered.

Notes: 
UC Policy
Location: 
Credentialing of Professional Staff

II.B.5.a

Completion of a formal reappointment application which includes, at a minumum:

1. Updated personal information

2. Completed attestation questions found in 2.II.B.3.g.

3. A formal statement releasing the organization from any liability in connection with credentiallng decisions

4. A formal statement confirming that the information submitted is accurate and complete

5. Applicant signature and date

Notes: 
UC Policy
Location: 
Credentialing of Professional Staff
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