A method of tracking who accesses the record in order to deter unauthorized access for electronic records.

Audits, EMR capabilities


The governing body meets at least annually, or more frequently as determined by the governing body, and keeps such minutes or other records as may be necessary for the orderly conduct of the organization.



Developing and maintaining a written policy regarding the care of pediatric patients, if relevant.  Specific components of perioperative care are listed in Standard 10.1.CC.


The names and addresses of all owners or controlling parties (whether individuals, partnerships, trusts, corporate bodies, or subdivisions of other bodies, such as public agencies or religious, fraternal, or other philanthropic organizations) are available upon request and furnished to AAAHC.

Delegation of Authority


Effective Date: 
Fri, 08/29/2014
Thu, 02/08/2018
Tue, 05/12/2015

The UCSC Student Health Services makes every effort to provide interpreter services for our student patients.


Interpreter Services


Use the Language Line Services, phone or iPad  to use the Language Line Interpreter Services.   Quick Reference Guide for phone access are provided in all the clinical exam rooms and in References in the EMR (Electronic Medical Records).  Instructions for iPad use (see below) are attached to the iPad and in References in the EMR.



Student/patient preference:

i. Arrangements can be made with contracted providers or the Disability Resource Center (DRC) for in-person interpreters with ASL capabilities, in advance of an appointment.  

ii. iPad can be used for ASL interpreters in the moment.  The iPad is mounted on wheels for access from reception through visits in the SHC or CAPS and ancillary services. 

Follow the instructions attached to the iPad cart.  When moving the iPad, between SHS services, the connection may be lost.  If that occurs, call the service back.



Make arrangements with DRC for ASL interpreters for group presentations.


Effective Date: 
Tue, 08/26/2014
Mon, 01/29/2018

UCSC has specific processes for different types of reimbursement.  These can include travel, purchases made on behalf of the department etc.

The UCSC Student Health Services reimburses employees for pre-approved purchases and for pre-approved continuing education leave and programs, and for other required meetings on behalf of the unit, when the UCSC reimbursement policy is followed.

Supervisor review and approval is required prior to initiation and submission of official forms.  Once complete, these forms must be also be reviewed and approved by the employee's supervisor.

Reimbursement will not occur if the policies are not followed.  The UCSC policy is subject to change and must be referred to prior to submission. (See Key Points and attachments below.)



  • Prior approval from a supervisor for a purchase is required
  • An employee "Payee Set Up" form is required prior to reimbursement (204 Form), to be done once in the staff member's career unless there has been a change in address or, in the case of direct deposit, a change in banking institutions. 
  • A direct pay form must be completely filled out, with all original, itemized receipts attached and submitted to the supervisor for review prior to submission to the SHS Business Operations Team (credit card receipts are not acceptable)
  • Certain items may not be purchased under Direct Pay.  Please refer to the Reimbursement and Payment guidelines on the Financial webpage.
  • Forms must be submitted within 30 days


  • NOTE: All travel requests must be pre-approved by the Executive Director or other Directors
  • Supervisor review and approval is required prior to travel and initiation and submission of all forms
  • Completed forms must be reviewed and approved by the supervisor
  • All UCSC policies must be followed for reimbursement to occur  Note: UCSC policy is subject to change and must be referred to prior to submission (see Key Points and attachments below)
  • Note: UCSC Business travel is not allowed in some states due to discriminatory policies.  Be sure to review the campus links for Pre-Travel for an up to date list

Travel Specifics

  • The Travel Advance Form must be submitted prior to ANY approved travel
  • If pre-payment is needed, apply in advance (at least 4 weeks) and use the Travel Advance Form with all the supporting documentation
  • Use the campus travel agency, Connexxus, whenever possible (with access to special UC rates): see link below
  • Do not use web travel agents, or group or package deals (i.e. Kayak etc.), since itemized statements are required and are not provided for those sites (and will not be reimbursed)
  • Keep all original, itemized receipts and attach them with the forms submission, along with the conference/meeting brochure or schedule; meeting agenda/s; for hotels/lodging, an original "folio" from the hotel is required
  • Vehicle rentals must be standard or economy.  Upgrades are not acceptable EVEN if less expensive.  Upgrades will NOT be reimbursed UNDER ANY CIRCUMSTANCES
  • Mileage reimbursement - attach a "Google Maps" or "Map Quest" print out from UCSC to the destination if traveling during working hours.  If traveling on non-work hours, the print out from your home address is acceptable
  • Meals are reimbursable only if traveling overnight, for greater than 24 hours, with a daily maximum. Original receipts must be attached.  Example: If travel is for San Francisco and the employee drives back and forth from home each day, meals are not covered
  • Alcohol is NOT covered
  • Submit forms and receipts within 30 days
  • Paying for another employee's travel will not be reimbursed


Key Points: 
  • Seek approval from manager prior to travel
  • Pre-Travel forms must be submitted prior to any approved travel
  • Submit reimbursement forms within 30 days of travel
  • Use the campus travel agency, Connexxus, whenever possible (with access to special UC rates); see link below
  • Do NOT use web travel agents or  group or package deals (i.e. Kayak etc.), since itemized statements are required and are not provided by those sites
  • Keep all original, itemized receipts and attach with the forms submission, along with conference brochure or schedule
  • Alcohol is not covered
  • Do not pay for another employee's travel

E.06.f. Note:

Note: A single quality improvement study may include more than one of the five topic areas listed above.


Clinical study.


Continuity of care.


Comprehensiveness of care.

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