Effective Date: 
Mon, 04/01/2002
Thu, 04/19/2018
Mon, 08/12/2019


2. The Hazardous Waste Management Policy includes guidelines for the proper handling of contaminated trash, sharps, and lab specimens in the clinic area and the disposal of other hazardous waste.
3. All personnel use proper practices in the handling and disposition of infectious waste to effectively control the spread of infection.
4. Infectious waste includes, but is not limited to, the following:
a. Syringes, needles, and I.V. sets
b. Surgical blades
c. Dressings from draining wounds
d. Any material which comes in contact with a draining wound
e. Human tissue/specimen not sent for pathological evaluation
f. Blood elements, excreta, and secretions
g. Disposable equipment/supplies used for the care of the patient
h. Any other material presenting a threat of infection
Staff are trained on proper identification, management, handling, transport, and disposal of all hazardous materials and wastes.
1. Hazardous waste trash receptacles are labeled as such and lined with red bags. Only trash that is saturated with blood is considered hazardous waste for the purpose of utilizing this disposal system.
2. Nursing personnel is responsible (not custodial staff) for the emptying of biohazardous wastes - to be disposed of daily if there are any contents.
3. Staff member wears gloves and other items of PPE (i.e., lab coat or gown) while handling biohazardous waste.
4. The red bag is removed from the can and closed securely.
5. The red bag is transported to the laboratory and put in the biohazardous waste cans for pickup.
6. A fresh bag is readied in the hazardous waste can for subsequent use.
1. All employees handling bodily fluids or lab specimens wear personal protective equipment (PPE) as indicated by the anticipated risk of performing the task. Gloves, gowns, masks, leg coverings and booties or full suit etc. are readily available in convenient locations for the handling of specimens.
2. Clinical or utility areas where lab specimens are processed (POC testing only) are clearly designated regarding clean or dirty for the purposes of defining where various tasks are performed.
3. Hand hygiene is performed at a station separate from the dirty utility sink area.
4. All specimens are sent to the lab in transport trays for processing and/or disposal.
5. Transport trays are cleaned by laboratory staff after each use.
1. Puncture-proof sharps containers are located throughout the patient care areas, secured in a manner to prevent tampering.
2. These specialty collection units are for the proper disposal of needles, syringes, scalpels, and any other sharps items that fit easily into the puncture-proof sharps collection boxes.
3. The sharps containers are removed when filled to the "fill line" by the nursing personnel and are replaced with new containers.
4. The full sharps containers are stored with the hazardous waste bags in the designated, closed container located near the lab.


1. Pharmaceutical waste must be incinerated. The SHC uses a third party reverse distributor for returning unused and expired medications as much as possible.

2. In the SHC, all partially used non-hazardous, pharmaceutical waste must be collected and stored in an alternate, approved sharps container, labeled "incineration only". The pharmaceutical sharps container is segregated and placed in areas in the SHC where pharmaceuticals are prepared and used for patient administration.

3. Only partially used vials, syringes and ampules of pharmaceutical waste need to be deposited in the pharmaceutical waste container. Empty vials, glass or otherwise, and without PHI, may be thrown into regular trash. Empty is commonly accepted as less than 3% of original total volume and there are no pourable contents. Broken glass vials and ampules need to be placed in a regular sharps container. Non-pharmaceuticals, including sodium bicarbonate, sodium chloride and water for injection may also be thrown into regular trash. Examples of pharmaceuticals to be placed into the pharmaceutical waste containers include the following: lidocaine and other injectable anesthetics, injectable ketorolac, injectable sumatriptan, injectable steroids, injectable ondansetron, injectable promethazine and ceftriaxone.  It also includes epinephrine. Other injectable hazardous drugs (HD) including medroxyprogesterone (Dep-Provera), testosterone and estrogen vials, empty or partially full, must also be deposited into pharmaceutical sharps containers.

4. A full pharmaceutical waste container may be stored for up to 90 days and a partially full container must be disposed of annually. The containers have a sticker that must be dated when the container is operational. These full pharmaceutical waste containers will be collected and stored separately from the biohazardous waste, and our biohazardous waste hauler will collect, document via manifest, and haul, both types of sharps containers plus biohazards.

5. Patients and visitors can dispose of expired medications and other pharmaceutical waste in the "waste" kiosk at the Pharmacy. Vitamins, minerals, fiber supplements, etc., can be disposed of in the regular trash.

E. Other Hazardous Waste

All other hazardous waste that must be collected is done via the Environmental Health and Safety (EH&S) department using their On Line Waste Tag system - WASTe (includes Trichloroacetic Acid, thimerosal and reagents etc.). 


Effective Date: 
Wed, 09/08/2010
Mon, 04/16/2018
Mon, 04/16/2018

The SHC uses only approved decontamination/disinfecting agents for general cleaning, processing of instruments, hand hygiene, skin preparation for procedures, etc.  All such agents are approved as indicated by the Infection Control Committee.  Information regarding all approved products can be found in the departmental SDS / Hazard Binders and on the Products Use Charts located in the Utility Rooms. 

Key Points: 
Decontamination: The process of removing rather than destroying microorganisms.
Disinfecting: An intermediate measure between physical decontamination and sterilization.
Sterilizing: The destruction of all forms of microbial life.


Effective Date: 
Tue, 09/07/2010
Mon, 08/13/2018
Wed, 08/17/2011

Airborne bacteria, viruses, and other agents may lead to infections. The Air Quality Policy assures that all staff/personnel, patients, and visitors are at a reduced risk for exposure to airborne pathogens and environmental agents.



  1. The intake system for the SHC building vacuums outside air into the ventilation system of the building and flows into each individual patient room, hallways, bathrooms, etc.
  2. The air is not re-circulated through the system but is instead pumped to the outside through a separate air-exit unit.
  3. There is an optimal circulation of environmental air in each room/space in the SHC buildings with a minimum of seven air exchanges per hour.





Key Points: 


  1. The number of air exchanges per hour (6) serves as a guide to determine how soon an exam room may be used after a patient with a serious respiratory infection is discharged. Details are found in the “Transmission Based Precautions" policy.
  2. The longest ‘rest period’ for an air-contaminated exam room (i.e., SARS or Avian Flu) is one hour.






Effective Date: 
Sun, 09/01/1996
Sat, 05/19/2018
Fri, 08/26/2011

The Student Health Center is not a teaching facility and does not provide formal teaching programs, with the exception of Counseling and Psychological Services (CAPS) Internship Training Program.

Under certain circumstances, limited internships are provided for students in various programs such as Health Career majors, Chancellor’s Undergraduate Interns (CUIP), and local vocational programs (ie. Medical Assistant training).
With the Executive Director’s and department supervisor’s permission, the Student Health Center (SHC) employees may permit a colleague or student to “shadow” them for brief periods. In these instances, the student may not under any circumstances deliver any care or assume any responsibility for a patient. All the guidelines for students/interns apply in this instance.
In all instances, the Executive Director’s approval is required before the student/internship commences. The department supervisor assumes full responsibility for management of the student/intern and for compliance with SHC policy. The department supervisor is responsible for serving as the liaison with the training program and understanding the student’s skills and limitations. In the clinical setting, the student/intern operates under the direction of the department supervisor or designee and may not independently assume responsibility for any patient care.
The student/intern is identified by nametag including name, job title, and student/intern designation. In the clinical setting, the student introduces him/herself (i.e. “I’m John Doe, a Medical Assistant student”) or is introduced by the staff member to the patient. If the patient so requests, the student/intern does not participate in that patient’s visit. If a SHC staff member is not present, the student/intern introduces him/herself by name and status.
An orientation must occur for any internship where private health information is discussed or present. This orientation will include, but is not limited to HIPAA Privacy and Security training and signing of the Confidentiality Statement.
CUIP Internships
The Student Health Outreach and Promotion Director is responsible for coordinating and overseeing SHC CUIP internships. These interns function in health promotion and outreach capacity and do not participate in clinical functions or direct patient care requiring access to Private Health Information. CUIP interns are required to comply with Student Health Outreach and Promotion confidentiality training requirements.
Student Internships
Occasionally the SHC may provide internship opportunities for local training programs such as the ROP Medical Assistant program. As for other student/internships, the Executive Director’s approval is required. The department supervisor is responsible for managing the internship including understanding the student’s level of training and learning objectives, insuring that clinical assignments are appropriate, and providing for proper supervision. An internship training agreement meeting current UCSC campus standards is maintained by the Student Health Center.  
CAPS Internship Training Program
See CAPS Manual, Training Programs
Key Points: 
  • The Student Health Center is not a teaching facility.
  • Limited internships are provided for specified students.
  • The Executive Director’s approval is required for any student/intern experience.
  • The department supervisor is responsible for a specific student/intern.
  • The student/intern never operates independently, assumes responsibility for any patient care, or signs any medical record. Patient care and documentation is always the responsibility of the Health Center employee/mentor.
  • All students/interns receive Student Health Center orientation as appropriate to their primary assignment including HIPAA, Confidentiality Statement and OSHA bloodborne pathogen exposure standards training before participating in clinical activities.
  • All students/interns wear nametags identifying their name, job title, and student/intern designation for example: J. Doe, Medical Assistant Student.
  • The patient has the right to refuse the presence of any student/intern.


Effective Date: 
Sun, 09/01/2002
Wed, 05/23/2018
Tue, 01/30/2018

Patients who require immediate access to further care and evaluation will be transported by appropriate methods to Dominican Santa Cruz Hospital Emergency Department unless on divert status and then will be directed to appropriate designated alternative facility. For patients needing acute psychiatric evaluation and care refer to Crisis Hospitalization Policy and Procedures for Involuntary Hospitalization (5150 Hold).

The treating provider is responsible for the decision to transfer the patient, and will direct the selection of receiving facility and mode of transport taking into consideration the acuity of the patient and the safety of the patient during transport.
1. Indications for Transfer/Transportation
a) unstable condition
b) ongoing medical monitoring or therapy is required
c) patient condition is beyond the scope of practice at UCSC SHS
2. Choosing the appropriate destination and means of transport for the patient:
In choosing destination and means of transport, the treating medical staff member will evaluate
a) the patient’s stability and potential for decompensation en route to the receiving facility.
b) any special circumstances required during transport (eg. Immobilization, advanced airway management, cardiac arrhythmia)
3. Urgent and Emergent Cases will be transported to the Emergency Room at Dominican Santa Cruz Hospital Emergency Department unless on divert status and then will be directed to appropriate designated alternative facility.
4. Ambulance Transport is Indicated for Patients
a) whose condition is unstable (head injury, abdominal pain, active bleeding)
b) who require special handling during transport (immobilization, emesis, severe pain)
c) who require medical monitoring during transport
d) for whom immediate further evaluation is necessary
5. Private Vehicle Transportation
  Transport in a private vehicle is contraindicated if the patient is driving themselves when there is a condition which would potentially impair their ability to drive (eg, extremity injury, significant pain). In these cases, another driver may be sought to drive the patient’s vehicle or give the patient a ride. Patients with stable vital signs and stable medical conditions may be transported in a private vehicle. Staff are not authorized to provide transportation in private vehicles.
6. Making Transportation Arrangements
a) Call 911 and advise dispatcher that  Ambulance Transport from the Student Health Center to Dominican Hospital is required. A diagnosis or chief complaint should be given. The time of the call will be documented in the medical record.
b) The treating clinical staff member should make direct contact with the receiving physician/facility to obtain acceptance of the transfer and document in the medical record.
Non-Emergent Transfers
c) Non-emergency ambulance transfers should be arranged through campus dispatch at 911.  Inform dispatch of the nature of the problem, our location and the destination. In collaboration with Santa Cruz County EMS, it was agreed that SHS personnel will inform dispatch that fire department respond is not needed.
d) Taxi transport for appropriate patients can be arranged .  Taxi vouchers are available. Two vouchers may be given if transportation to and from the hospital or doctor’s office is needed.
7. Role of Paramedics
a) Paramedic crew will assume responsibility for the patient on their arrival at the scene, and will treat patients according to their protocols.
b) The UCSC physician remains at the health center and communicates with the ER physician by phone.
8. Documenting Transport/Transfer of Patients
a) Document that the receiving facility was notified and accepted the patient for transfer in the electronic medical record using the hospital transfer section.
b) A copy of the draft progress note should accompany the patient, containing the essential findings and summary of care provided at UCSC SHS, along with the patient’s condition at the time of transfer.
c) An Incident report will be created for all transfers.
d) If appropriate, request that the student sign the Release of Health Information to allow the Student Health Center to contact Student Services.  If the student signs this, document that Student Services was notified.  This allows Student Services to offer support services to students with unexpected medical situations.


Effective Date: 
Sun, 09/01/1996
Tue, 03/13/2018
Tue, 11/22/2016

Incoming diagnostic test results (lab, radiology, EKG, etc.),clinical summaries from consultants, and other medical records are reviewed and acknowledged by the ordering clinician or designated coverage in a timely fashion. Patients are informed at the time tests are ordered how they will be notified. Unless otherwise arranged, lab and x-ray results will be communicated by secure electronic messaging.


Laboratory and x-ray results are downloaded into the EMR (Point and Click or PNC).  Laboratory results are directly loaded from Quest into the EMR with a patch program.  Radiology results are electronically sent from the Radiology Medical Group and are uploaded directly into the EMR.

These results appear in a "folder" in the EMR called the Provider Task Summary

Clinicians are responsible for reviewing contents of their individual Provider Task Summary at least daily and manage as clinically appropriate. Clinicians are responsible for notifying patients of all of their diagnostic test results.

For self-directed testing for Sexually Transmitted Infections, RNs review results.  Pre-written text messages are sent for negative test results.  Positive STI test results are forwarded to the Medical Director or Patient Care Coordinator for management.

After reviewing diagnostic test results,  the clinician clicks the "send message" button below the result and attaches an note explaining the significance of the result and any follow up that is indicated.  This creates a dated, electronic signature indicating that the clinician has reviewed the result and the patient has been sent a secure message.

Additional options for acknowledgement are available in the EMR.  These options allow the clinician to put a note on the lab or indicate that the clinician called or sent a secure email message to the patient regarding their results.  The clinicians are expected to send all lab results, both normal and abnormal, to the patient using secure message unless other specific arrangements have been made.  For common labs, a variety of pre-written text messages are available to clinicians to send to patients regarding test results.

Some diagnostic test results, letters from consultants, or copies of past medical records come to the Student Health Center by fax or mail.  These results are logged on arrival in Medical Records, date stamped, and each result placed in an individual red folder.

The charge nurse reviews fax and paper results and delivers them to the clinician working with the patient.  If no clinician is identified then the result goes to the Patient Care Coordinator.

Part time and per diem clinicians have their lab and X-ray results reviewed by a career clinician assigned to cover them when they are not working on site.

Fax and paper results are initialed by the clinician, returned to Medical Records, and then scanned into the EMR.  These results appear in the section of the EMR called Scanned Documents.  These results are not in the sections called Laboratory or Radiology.

To assure that no results are lost, the Lab and X-Ray Depts track all studies from collection through to results.   Each department maintains a daily log of all tests done.  Each log entry is maintained as an active send out list until results for every test have been entered into the EMR.  This allows timely identification of any results exceeding the expected turn around time.

  • Labs sent out to reference laboratories which do not return within the expected turnaround time will be tracked by the UCSC SHC  lab staff.  The UCSC SHC Lead Clinical Lab Scientist or designee will contact the reference lab and expedite transmission of the final lab result.
  • The daily list of X-rays sent out to for interpretation to the consulting Radiology Medical Group is maintained and monitored by the X-ray technologist.  In the case of a delay in receipt of an X-ray report, the R.T. will contact the Radiology Medical Group administrator to expedite the report.
Key Points: 
  • All diagnostic test results appear in the ordering providers inbox.
  • The EMR allows the clinician to electronically acknowledge test results and generate secure email messages to patients about those results.
  • Patients are notified of all lab and X-ray results via secure electronic messaging unless other arrangements are documented.
  • Fax and paper reports are logged, date stamped, and sent to the appropriate clinician for review.  The clinician initials and dates the paper report and returns it to Medical Records where it is scanned into the EMR.
  • Both lab and X-ray maintain daily logs to track the status of all studies sent out from the Student Health Center.  These logs are monitored to prevents inadvertent delay or loss of a lab or X-ray final reports.





Effective Date: 
Wed, 01/01/2003
Fri, 05/15/2015
Fri, 05/15/2015
The UCSC Student Health Center supports a team of providers to care for students with eating disorders.  
Specific medical, nursing, psychiatric, counseling and nutrition staff members are designated to provide care for ED students.   The team meets monthly during the fall, winter and spring quarters  to discuss management of specific cases, support one another in providing care, and keep up-to-date on best practices in the care of the eating disordered patient. Off campus therapists who work most closely with our eating disordered patients are invited to join this monthly meeting.
The Patient Care Coordinator chairs the Eating Disorder Care Team.  The PCC regularly reviews the EMR to identify active ED students and providers extra support to ED students requiring active surveillance.  
The role of the Student Health Center in the care of the Eating Disordered patient is identification of students with Eating Disorders, appropriate evaluation for medical complications, and referral for psychological counseling.  
The Student Health Center does not provide intensive outpatient services. 
In cases where more intensive medical care, exceeding the capacity of the Student Health Center ,is required.the Patient Care Coordinator works with the therapist, the patient, and the family to identify a more appropriate source of care.
In cases where a patient fails to agree to recommendations for a higher level of care,the policy on Involuntary Medical Withdrawal outlines the specific steps to be taken when an Eating Disordered student is unable to safely care for themselves and must be asked to leave school.  
Students with eatings disorders are identified by providers or present themselves for care. 
This diagnosis is entered onto the patient's Problem List. 
If the initial visit was with a provider not on the ED Team then follow up should be scheduled with a clinician on the ED team.   
A 40 minute intake appointment is made with a medical member of the ED Team for an initial evaluation. 
The clinician should specifically document the patients medical acuity. 
Every attempt should be made to link patients to mental health care.  If possible, a Release of Information to work with the therapist should be obtained.   
Frequency of follow-up visits with the clinician is based on clinician and therapist levels of concern. 
The student should be encouraged to use the additional services available at the Student Health Center including both the services of our nutritionist and the opportunity to join the Eating Awareness group run by CAPS.  
If appropriate, a psychiatric evaluation may be scheduled.  
The Patient Care Coordinator facilitates a monthly meeting of those professional staff working with Eating Disordered students.  
These meetings include a continuing education component, an opportunity to discuss difficult situations, and a review of high acuity cases.  The meeting includes an opportunity to seek help with difficult situations from oher colleagues. 
If a clinician determines that a student's eating disorder has reached a life threatening acuity or their behavior puts them at grave danger, the clinician may request that an Ad Hoc Committee be convened to consider requesting that the student be placed on involuntary medical leave in order to receive a higher level of care.   This process is delineated in the policy on Involuntary Medical Withdrawal.  
The Patient Care Coordinator works with the families of Eating Disordered students as necessary to help identify an appropriate plan of care, including hospitalization.
Key Points: 
  • Specific providers in the Student Health Center care for students with Eating Disorders. 
  • These providers make up the Eating Disorder Care Team which meets monthly for continuing education, support, and clinical case review to maintain a high level of quality care for the eating disordered student. 
  • The Student Health Center clinicians monitor physical complications due to eating disorders but recognizes that therapy is the cornerstone of treatment for eating disorders.  Clinicians collaborate with the student's therapist to provide care..  
  • In the event that a clinician feels that a students condition is grave or life threatening, every attempt should be made to facilitate moving the student to a higher level of care.  If these attempts are unsuccessful, an Ad Hoc Committee can be convened to consider placing the student under Involuntary Medical Withdrawal.
  • The Patient Care Coordinator regularly reviews the EMR to identify Eating Disorder students and to review acuity. 


Effective Date: 
Thu, 09/15/2011
Wed, 09/05/2018
Wed, 12/04/2019
Use of the AED is a component of the American Heart Association Basic Life Support (BLS) standards of emergency care. The Student Health Center maintains automatic external defibrillators (AED) for use in emergent situations. Education and training are provided to ensure staff competency in the use of the AED.
The AED is used to detect shockable rhythms in the event of a cardiac arrest and, if indicated, automatically defibrillate patients in acute cardiopulmonary distress while the Emergency Medical System (EMS) is activated by dialing 911.
The AED is checked daily by nursing, CAPS, lab and pharmacy personnel.
When used, the Santa Cruz County "Notice of AED Use" form will be filled out and submitted.
Note: See manufacturer Operating Manuals, for detailed instructions on specific AED operations:. 
LifePak 1000 AED located in Same Day Clinis Nurses station
Zoll AED Plus located: 1-  in Westwing, Floor 2 Nurses station; in East Wing Floor 2 near CAPS; and 1 in East Wing Floor 1 Pharmacy Lobby
Simplified Operator's Guides are stored with each AED.
AEDs are located in five areas of the clinical spaces of the Student Health Center:  1)  Floor 1 West Wing in the Treatment Room on the red cart;  2)  Floor 2 West Wing on the wall in the corridor outside the Treatment Room; 3) Floor 2 East Wing near CAPS; 4) Floor 1 East Wing near the Pharmacy; 5) Basement in Laboratory.   Daily checks are performed as per manufacturer instructions by the Same Day Clinic Nurse or Charge Nurse designee, and CAPS, Lab and Pharmacy staff, and documented on the checklist logs located near each AED. Daily checks include:
LifePak 1000 
-pad expiration date
-status dispay for full battery should say "OK".  If shows 1 bar or less or wrench symbol = notify supervisor
-check for presence of damage or cracks or foreign substances
Zoll AED Plus
-pad expriation date
-status display should be green check mark.  If red "x" notify supervisor
NOTE: AED's are located throughout campus for use as needed.  SHS staff who work away from the Student Health Center can refer to the shared campus list:
Additionally, if an AED is used, then the Santa Cruz County "Notice of AED Use" form will be filled out and submitted. See attached.


In the event of an emergency, the AED is brought to the patient for immediate monitoring and defibrillation if indicated. Any trained staff member may initiate the use of the AED by placing the pads on the patient and following the machine’s commands.
Annual staff training in the use of the AED occurs during Fall orientation. Use of the AED is also included in biannual BLS certification training. Additional training occurs throughout the year as needed, for example during the orientation of newly-hired clinical staff, and with the purchase of new equipment.
Periodic emergency drills are held in order to review emergency procedures including use of the AED.
Key Points: 
  • Automatic external defibrillation is a component of BLS standards of emergency care
  • Staff training on the use of the AED is provided by the Student Health Center
  • An AED is stored on Floor 1 and Floor 2 of the West Wing Clinical areas,  Floor 1 East Wing near the Pharmacy, Floor 2 East Wing near CAPS, and in the basement in the Laboratory, and are checked daily per manufacturer’s instructions
  • An AED is taken to the patient in the event of emergency
  • Any trained staff member may initiate use of the AED
  • AED's are located at many locations throughout campus


Effective Date: 
Sun, 09/15/1996
Tue, 03/13/2018
Thu, 05/14/2015

All notes and other materials incorporated into the medical record are appropriately signed and dated by the professional staff creating or reviewing them.


1. All outside documents are acknowledged by a clinician by initialing and dating receipt of the report.  The acknowledged report is  scanned into the chart.   Alternatively the report is scanned into the chart, placed in the appropriate clinician's Provider Summary section where it's receipt is acknowledged by the clinician.

2. Entries into the medical record by Nurses acting under Standardized Procedures and Protocols are cosigned by a supervising clinician, usually within 24 hours, and always within 1 week of the date of entry according to the following guideline:

  • All Nursing visits for illness or injury not covered by Advanced Nursing Protocols.
  • Cases where clinician consultation is documented in the case note.

3.  Documentation is to be completed within 24 hours of the patient visit or call.  A daily report is run in Medical Records to identify documentation which is not compliant with this policy.  Individual clinicians are notified of outstanding documentation daily.  Recurrent failure to meet this policy is reported to the clinician's supervisor by the Medical Records Systems Administrator.

4. Telephone contact with a patient is clearly identified as such in the medical record.

5. Errors are corrected by creating an addendum. If an entry has been mistakenly entered in the wrong patient chart, the staff responsible for the error will contact their immediate supervisor and follow the Medical Records Standard  for correction.

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