Student Orientation Handbook

Student Orientation
Handbook
Terre Haute Regional Hospital
Educational Services
Director: Lori Magee, RN, MSN, CNOR
[email protected]
Educator: Carrie Deakins, RN, BSN
[email protected]
Educator: Shelley Harkins, RN, BSN, CCRN
[email protected]
812-237-1277
Created 7/2012. Edited 6/2013, Edited 11/2013
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Table of Contents
General Information: Required paperwork
About Terre Haute Regional Hospital
Mission, Vision, and Values of THRH
Corporate Compliance
General Student Obligations
Environmental Safety
HIPAA
Emergency Codes
Customer Service
Patient Rights
OSHA requirements
Infection control, isolation
Occurrences and events
Abuse and neglect
National patient safety goals
Age Specific Competencies
Cultural Diversity
Harassment/Violence in the workplace
Quality Regulations
Parking
Student Regulations
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Dear Students and Faculty,
The Education Department of Terre Haute Regional Hospital would like to
welcome you to our hospital on behalf of the entire Regional family. Thanks for
choosing us as your site for clinical rotation.
We hope the experience will be a stepping stone to a great career within healthcare.
Further we hope the opportunities and experiences you gain here will mold you into
a great future healthcare partner.
Please remember Terre Haute Regional Hospital’s mission, vision and values as
you interact with our customers at the hospital. Please provide us with any feedback
about your experience so we can continue to exceed expectations.
Here’s to a great clinical.
Sincerely,
Education group
Terre Haute Regional Hospital
Education Department
812-237-1277
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General Information
Standards: Students will be held to the same standards that all of our competent professionals are when performing their
duties.
Cell Phones: Students are to follow the rules and regulations set forth by their school or program. Cell phones are not
permitted in patient care areas and should not distract from duties and care.
Cafeteria: The student will be charged regular price for meals purchased while on clinical at our facility.
Smoking: Smoking is prohibited at Terre Haute Regional Hospital; the entire campus is smoke free.
Liability: Liability insurance is provided by the individual education institution.
All students who are involved with patient care are required to have:
1. A background screening (either done here or be able to provide us with a copy from their institution, or sign the
attestation attached to the affiliation agreement. Make sure all criteria included)
2. A current drug screening (either done here by scheduling with Carole Pitts at 237-9880 for a fee, a copy from a drug
screen done at another facility, or again the attestation signed at the end of the affiliation agreement.)
3. Immunizations to include proof of immunity to MMR (either 2 doses or positive tier), chicken pox-Varicella (2
doses or physician documented disease or positive tier) and including flu (provide copy or get with Carole if they are not
up to date) All students must provide a copy of their flu shot if they will be in the hospital Nov 1-March 31st. I will give
them a sticker for their badge once received.
4.
TB – tuberculosis testing- current 2 step TB test. (Must have 2 tests within the past 12 months)
5.
Current CPR copy
6.
A schedule of their start and end date of clinical
7.
A photo ID badge (ISU does not have photo ID badges so they need to go to HR and get one made.)
8.
A copy of their government issued photo ID, preferably driver’s license.
Personal Belongings: The hospital is not responsible for the loss of personal items. Please leave personal items, such as
jewelry, cash, and computers at home or locked in your car.
Staff Break Rooms: Staff Break rooms are for the use of our staff during their off/down times to relax and unwind.
Please do not use these areas as places for clinical meetings, post conferences or classrooms unless prior arrangements
have been made. Classrooms on the main floor can be reserved for such uses by calling the Education Department during
regular hours.
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What do you need to do?
Required forms must be returned to the Education Department on 3rd floor, completed during
orientation or emailed prior to your clinical start date.
(You cannot start clinical until all is received, including 1-8 listed above)
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Confidentiality and Security agreement signed (FORM A)
Security Access form (FORM B)
Statements of Responsibility form- fill in your school’s name, sign & date. (FORM C)
Parking acknowledgement (Signed page 2) (FORM D)
HIPAA test (FORM E)- answers can be found in the booklet
Attestation of Student orientation book (FORM F)
About Terre Haute Regional Hospital
Regional Hospital is a 278-bed community-based medical center with comprehensive medical and surgical
programs. Terre Haute Regional is accredited by The Joint Commission. In 2006, Regional Hospital became the
first Wabash Valley Hospital to be designated as an Accredited Chest Pain Center by the Society of Chest Pain
Centers and Providers.
These accreditations help further Regional Hospital’s rich history of providing sophisticated care to the Wabash
Valley community for over 129 years -from its beginnings as St. Anthony’s Hospital to the present day facility.
In 1882, St. Anthony’s Hospital began as the only healthcare facility in the area. Together with the Sisters of St.
Francis, St. Anthony’s Hospital served our community until 1975 when it was renamed Terre Haute Regional
Hospital. In 1979, a modern five-story hospital complex was built on the south side of Terre Haute to replace
the original building.
Terre Haute Regional Hospital was recently named one of the nation’s top performers on key quality measures
by The Joint Commission, the leading accreditor of health care organizations in America. Terre Haute Regional
Hospital was recognized based on data reported about evidence-based clinical processes that are shown to
improve care for certain conditions, including heart attack, heart failure, pneumonia, surgical care and
children’s asthma. Terre Haute Regional Hospital is one of only 405 U.S. hospitals and critical access hospitals
(one of five in Indiana) earning the distinction of top performer on key quality measures for attaining and
sustaining excellence in accountability measure performance. Inclusion on the list is based on an aggregation of
accountability measure data reported to The Joint Commission during the previous calendar year. For example,
the initial recognition was based on data reported for 2010.
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Terre Haute Regional Hospital Mission, Values and Vision
Terre Haute Regional Hospital is an organization dedicated to its Mission, Values and Vision and is committed
to providing quality, individualized patient care to the communities we serve. Terre Haute Regional Hospital
looks forward to continuing to serve its friends and neighbors and growing with the community. We’re more
than a hospital, we’re a family!
I
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Integrity
Courage
Accountability
Respect
Exceed Expectations
In addition to this model we have an obligation to be respectful and sensitive to one another’s belief system. Be
sensitive to the following personal health beliefs and practices:
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How does the patient stay healthy?
What are the expectations for medicine usage?
Family and community relationships
Language barriers
Body language
Cultural factors
Religious/Spiritual beliefs
Corporate Compliance Program
As part of our commitment to provide quality care to our patients, we strive to ensure an ethical and
compassionate approach to healthcare delivery and management. We must demonstrate consistently that we act
with absolute integrity in the way we do our work and the way we live our lives.
The Code of Conduct emphasizes the shared common values which guide our actions. All THRH employees
attend Code of Conduct training on an annual basis and must be familiar with its content.
We expect individuals involved in patient care to abide by this Code of Conduct. In general, the following
applies to anyone working, training, or observing at THRH:
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Information concerning patients, employees and other THRH business of a confidential nature must not
be discussed with persons not concerned with such information, and certainly never with people outside
THRH.
Physicians have the training, primary responsibility, and legal right to diagnose and treat human illness
and injury.
A student/intern/observer’s conduct in his/her private as well as professional life should be consistent
with the responsible image that the hospital wants to project to patients, visitors, and the general
community.
Discussing personal issues/problems with patients is not appropriate.
Individuals in patient care must maintain a professional relationship with patients.
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Reporting Ethical Issues:
We at THRH encourage all staff/students to utilize the HCA Ethics hotline, 1-800-455-1996 if they feel they
need to report any concerns regarding the ethical conduct of its management or practices.
PROFESSIONAL IMAGE
We believe that when we create and present a professional image our patients and visitors feel safe, confident
and comfortable during their hospital experience.
Personal Identification
A Terre Haute Regional Hospital and/or school name badge-WITH PHOTO must be worn in a visible location
at all times while in the facility. ID badges are to be free of pins, stickers (with the exception of the flu sticker),
or any other material that might interfere with the visibility of the photo or the identification of the person
wearing the badge.
Personal Appearance
Students:
 Wear uniform from program
 Wear name badge
 No visible tattoos
 Hair must be tied back if longer than shoulder length
 No more than one small ring on each hand
 No visible body piercing other than one set of small earrings
 No artificial nails or extenders in patient care area’s
Student ROLES & RESPONSIBILITIES
Terre Haute Regional’s Role and
Responsibility
Provide orientation to students.
Withdraw any student whose
progress, achievements or
adjustment does not justify his/her
continuance with the program.
Provide suitable arrangements to
gain specific experience as outlined
in curriculum.
Inform students of applicable
policies and procedures.
School and Faculty’s Role and
Student’s Role and
Responsibility
Responsibility
Uphold patient and hospital
Wear identification badge.
confidentiality both in clinical areas
of the hospital and away from the
hospital campus.
Maintain accepted standards of
Comply with all licensing and
care.
regulatory requirements as well as
all Federal, State and Joint
Commission standards.
Complete and return student
Communicate with the assigned
evaluations as required by school.
preceptor regarding any change in
patient condition.
Notify THRH of any change to
Wear appropriate school uniform
student’s program or schedule.
and comply with facility dress
code.
Abide by the Facility’s policies,
procedures, and Code of Conduct.
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ENVIRONMENTAL SAFETY
Safety is Everyone’s Concern
Notify staff when you:
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See any criminal activity
See any suspicious circumstances
Need to report visitor accidents or visitor needs
Need an escort or vehicle assistance
General Safety
We are all responsible for
ensuring a safe environment for
our patients and guests. Notify a
hospital employee of any safety
hazards that you may identify.
These included frayed or broken
electrical cords/wires; spills on
the floor and any other hazardous
condition.
Never approach a situation in
which your security and personal
safety could be compromised. We
have specially trained personnel
available who will respond
immediately to a Code 999—
whether it involves a patient,
visitor, or staff.
There are very strict guidelines to
the use of restraints and, if at all
possible, they are to be avoided.
Restraints are only utilized in the
Emergency Room, the Intensive
Care Unit and the Behavioral
Health Unit. Terre Haute Regional
Hospital uses alternatives to
restraints to decrease the need for
this type of intervention. Check
with the Charge Nurse if you
believe the patient is at risk for
self-harm.
Patients who have been identified
at risk for falls are identified by a
bright yellow wristband, yellow
magnet on the door frames, and a
sticker attached to the patient’s
chart. Special precautions must be
observed to decrease the risk of
falls. Please, ask the patient’s
primary nurse which precautions
have been implemented for the
patient.
Unit Specific Material Safety
Data Sheets (MSDS) are kept
electronically on E-Resources.
These sheets will identify any
potentially hazardous chemicals in
use in your area. Master copies of
all MSDS sheets are kept in the
Emergency Center and in the
Facility Operations Department.
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HIPAA: PRIVACY & SECURITY OF HEALTH INFORMATION
Certain laws and regulations require that practitioners and health plans maintain the privacy and security of
health information. HIPAA stands for the Health Insurance Portability and Accountability Act of 1996.
The following is considered identifiable information and must not be accessed or shared for any purpose other
than patient care. Our Compliance Officer is April Holloway.
 Names
 Mailing addresses
 Dates related to the individual such as birth date
 Telephone numbers/ Fax numbers
 Email addresses
 Social security numbers
 Medical record numbers/ Account numbers
 Certificate/license numbers
 Vehicle identifiers
 Device identifiers and serial numbers
 URLs
 IP address numbers
 Biometric identifiers
 Photographic images
 Any other unique identifier
 Sensitive records such as substance abuse records, genetic test results, etc
** Your Computer ID or ¾ ID is not considered confidential
Additional steps to protect a patient’s privacy
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Close room doors when discussing treatments and administering procedures.
Close curtains and speak softly in semi-private rooms when discussing treatment and performing
procedures.
Avoid discussions about patients in public areas such as cafeteria lines, waiting rooms and elevators.
Safeguard medical records by not leaving the record unattended in an area where the public can view or
access the record.
If you logged into a computer system to view or chart on an electronic medical record, make sure to log
off once you are finished.
Do not share your computer access password with anyone. Take precautions to prevent others from
learning your password.
Before discarding any patient-identifiable information, make sure it is properly shredded or locked in a
secure bin to be destroyed later. Do not leave information in a trash can.
Do not use cell phone or other electronic devices to take or send photographic images and audio/video
recordings of patients and/or medical information.
Do not publish medical information, photo images or audio/video recordings on networking web sites or
blogs. This includes de-identified information. If you are ever in doubt about the policy please ask Terre
Haute Regional staff.
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Photographing, Video Recording, Audio Recording
& Other Imaging of Patients, Visitors and Workforce Members
Policy ADM.HIP.030 has been updated to reflect the use on new technology in video/audio
recording; i.e. goodle glass wear. In an effort to increase awareness and standardize the
proper use of cameras and other recording devices you are asked to review this policy.
Some of the highlights include:
 Written patient informed consent is required before workforce members may
photograph or audio record a patient for most purposes, including patient
care/treatment, telemedicine, or publicity.
 Consent to photograph or audio record a patient for security and/or health care
operations purposes is obtained via the hospital’s Conditions of Admission and
Consent for Outpatient Services.
 Patients, family members, and/or visitors are not permitted to take photographs
of or audio record other patients or workforce members without consent.
 Workforce members must only use designated company-owned devices to
photograph or audio record a patient.
 In general, patient consent is not required when photographing patients to
document abuse or neglect. However, the photographs must not be used for any
other purpose beyond submission to the investigating agency unless otherwise
permitted by federal or state law.
For any questions please refer to the full policy or contact April Holloway, RN FPO @ ext. *79338
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HOSPITAL EMERGENCY CODES
1. To reach Switchboard quickly, dial 1122 Emergency Line.
2. Switchboard will announce “NOW HEAR THIS” 3 times, then will announce CODE NAME
Code
Definition
General Response
RED
FIRE
Follow “Fire Plan” found in Disaster Manual for evacuation diagram and
specific department responsibilities
Red Drill
Fire Drill
Code GREEN
Fire All Clear
CONDITION A
CARIDAC ARREST-ADULT
Only trained medical personnel respond, If you are a member of the
patient’s care team please do not leave the room without communicating
with the code team.
CONDITION B
CARIDAC ARREST-CHILD
Only trained medical personnel respond, If you are a member of the
patient’s care team please do not leave the room without communicating
with the code team.
CONDITION C
(CRISIS) RAPID RESPONSE
TEAM
Only trained medical personnel respond. If you are a member of the
patient’s care team please do not leave the room without communicating
with the code team.
AMBER ALERT
CHILD ABDUCTION
Personnel should monitor hospital exits closest to them. All exits will be
monitored and staff will be stationed at all entries and exits.
CODE ER
BACK UP NEEDED IN THE
EMERGENCY ROOM
STAY IN YOUR AREA
CODE 999
DISTURBANCE
STAY AWAY FROM AREA
CODE BRAT
BIOLOGICAL RESPONSE
ACTION TEAM
STAY AWAY FROM THAT AREA
CODE 33
RADIATION CONTAMINATION
Radiation Safety Officer will direct all activities involving the
monitoring/decontamination of patients and hospital staff.
CODE ORANGE
HAZARDOUS MATERIAL
INCIDENT
AVOID AREA
CODE GRAY
TORNADO WATCH
ASSIST STAFF WITH PREPARING UNIT AND PATIENTS.
CODE BLACK
TORNADO WARNING
CODE WHITE
TORNADO CLEAR
RETURN TO NORMAL FUNCTION
CODE YELLOW
BOMB THREAT
IF ANSWER CALL, KEEP ON LINE, ASK QUESTION
CODE D
EXTERNAL DISASTER
Refer to Disaster Manual for specific responsibilities in your department.
Your immediate supervisor will define your specific response at the time
of the disaster.
DR. EASTWOOD
WEAPON ALERT
STAY AWAY FROM THAT AREA
CODE STEMI
ACTIVE Myocardial
Infarction/Heart Attack IN HOUSE
RESPONSE FROM ICU, RRT, CATH LAB AND ER IF NEEDED TO PREPARE
PATIENT FOR EMERGENCY CARDIAC CATH
CODE STROKE
ACTIVE STROKE IN HOUSE
ALERTS RADIOLOGY TO GET CT SCAN READY, RRT ARRIVES
Use R.A.C. E. Rescue, Alarm, Contain, Extinguish
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Customer Service
Greet others with a smile and eye contact
Practice the 5-10 rule in the hallways. At 10 feet make eye contact and at 5 feet speak.
Call patients by their names not by a room number or diagnosis
Always ask if there is anything else you can do for the patients before you leave their
rooms.
Always thank the patient for choosing our hospital to get their care.
Introduce yourself every time and thoroughly explain any procedure you may be doing.
Provide the patients and their visitors and family members with any education you can
give.
Apologize and recognize patient frustrations while trying to be a part of the solution.
PATIENT RIGHTS AND RESPONSIBILITIES
Terre Haute Regional outlines the rights afforded to each person who is a patient in our facility. The Patient
Rights and Responsibilities describe Regional’s commitment to an environment of trust-an environment where
patients can feel comfortable and confident with the care they receive. You have the responsibility to help us
carry out this commitment.
The Patient’s Rights Policy has been adopted to promote quality care with satisfaction for the patient, the
family, the physician, and the staff, regardless of race, color, religion, sex, age, national origin, physical or
mental disability, veteran status and/or the ability to pay.
OSHA: OCCUPATIONAL SAFETY AND HEALTH ACT
Students must fully comply with all of the following OSHA standards.
Hazardous Materials
If there is a spill of any hazardous material contact the MSDS hotline. The MSDS phone number is 1-866-9902522
“Sharps” Protective Devices
Use protective devices at all times to prevent needle sticks.
“Sharps” Disposal Containers
Immediately dispose of all sharp objects in the “sharps” disposal containers.
Personal Protective Equipment (PPE)
Wear personal protective equipment when there is potential for handling or coming in contact with bodily
secretions or fluids. PPE is available in the departments.
Pharmaceutical Waste
Maintain proper disposal of pharmaceuticals, follow regulations.
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Infection Control
Notify our infection control nurse with concerns or questions. Her cell is 230-1238, office 237-9289 or use
extension *72615.
Blood borne pathogens
When blood borne diseases are mentioned, most people think automatically of AIDS, but actually HBV,
or the hepatitis B virus, is much more common. According to the Center for Disease Control (CDC), as of
June 1994, there were 401,749 confirmed cases of AIDS in the U.S., and approximately 300,000 people
become infected with hepatitis B annually. It is estimated that a further 1.5 million people in the U.S. are
infected with HIV and that most are between the ages of 25 and 49 and are active members of the
workforce.
ANYONE WORKING WITH HUMAN BLOOD IS AT RISK!
What can you do………..Pay Attention! NEVER recap your needles
1. Universal Precautions
 Universal Precautions are the Center for Disease Control's
(CDC) recommendations for handling body fluids and blood
in the workplace. The CDC's position is that all body fluids
and blood should be handled as if they were contaminated.
2. Engineering and work practice controls
 Use autoclaves to sterilize all equipment and to treat infectious waste.
 Use puncture resistant, labeled sharps containers for disposal of needles, razor blades, etc.
 Do not break, bend or recap needles - place them directly in the sharps container.
 Do not pick up broken glass with your hands - sweep it up.
 Wash hands immediately after removing gloves and after any hand contact with blood
contaminated surfaces.
 Don't keep food or water in areas where blood is present.
 Don't eat, drink, smoke or apply make-up in areas where blood is present.
 Eliminate splashing of infectious materials when possible.
 Never pipette by mouth!
 Protect open wounds from infectious materials.
3. Personal protective equipment
 Employers must make available and employees must use personal protective equipment (PPE)
when the possibility of exposure to blood or infectious materials exists.
 Employees must be trained in the use of PPE.
 PPE must be accessible and clean.
 Disposable gloves must be replaced as soon as they are torn or punctured.
 Eye protection must be worn if there is a chance for a splash to occur.
 The level of protection required is dependent upon the task at hand.
4. Housekeeping issues
 Clean up all blood or body fluid spills immediately.
 Clean and decontaminate all surfaces and equipment which have been in contact with blood
thoroughly.
 Contaminated laundry must be handled with extreme caution and contact minimized.
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Types of isolation:
o Standard- for everyone
o Contact- MRSA, VRE, C-diff, open draining wounds
o Droplet- influenza, Pertussis
o Airborne- TB, Measles
Isolation signs are found on the doors of the patients rooms and if they
are in isolation, an isolation cart is found outside their door. The carts
come from central sterile supply department. The unit secretary
usually calls to have the isolation cart brought to unit. Restocking of
gowns, masks, etc. is from storeroom- X1147.
Standard Precautions
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Hand hygiene
Gloves (when touching body fluids or non-intact skin)
Gowns (if splashing might occur)
Masks and goggles (if aerosolization or splattering might
occur)
Needles (activate safety devices)
Patient specimens (treat all as bio-hazards)
REMEMBER, HAND WASHING BEFORE AND AFTER CARING FOR EACH
PATIENT IS THE MOST EFFECTIVE MEANS OF PREVENTING THE SPREAD OF
INFECTION. ALCOHOL BASED GELS ARE AVAILABLE THROUGHOUT THE
HOSPITAL. If your hands are visibly soiled you must wash with soap and water. Also,
you must wash with soap and water after every 8 – 10 washes with the alcohol based gel.
Injury Reporting
Report any exposure to blood and/or body fluid and any injury immediately to a
Terre Haute Regional employee and also report to your faculty/school.
Document any injury, including all exposures to blood and body fluids
(puncture wounds, splashes in the eye, fall or back injuries) to Employee
Health/Infection Control.
SUPPLIES AND EQUIPMENT:
Patient care supplies are available on the patient care areas in the supply rooms. Every item removed from the supply
room MUST be scanned. If the item is not scanned, it will not be replaced to the unit
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Back Safety
Be Nice to Your Back! Your back is an original and the only one you get! It holds you up all day long and assists you
with every day activities like lifting, bending, reaching and standing. Even the simplest activity, if done incorrectly, can
strain your back and cause permanent injury. Every year many healthcare workers suffer back injuries. Some of these
injuries lead to permanent loss of work. You can prevent injuries by:
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Use additional staff and mechanical equipment as needed to safely transfer, reposition or lift patients. Never
attempt to reposition a patient by yourself. Don’t overestimate the weight you can lift.
Keep your feet apart, with one foot next to the object being lifted and one foot slightly behind. This gives greater
stability and upward thrust.
Let your legs do the work, not your back. Keep your back straight and bend your knees, keeping your knees in
line with your feet, to get close to the object you are lifting.
Use your entire hand when lifting. Your fingers alone have very little strength. Wrap your fingers around the
object, with firm pressure from your palm, on the object.
Bring the load in close to your body with your arms and elbows tucked close to your side.
Position your body so that your weight is distributed inside your feet. This gives you better lifting strength and
better balance. Lift by using the strength of your legs and not your back.
Never twist your body from side to side when lifting or transferring. This is a major cause of back injuries. Move
your feet if you must change direction.
Don’t lift or carry objects above shoulder level.
NO PASS ZONE:
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Yellow triangles on walls
Remind us not to pass an active call light
We always check on the patient even if they are not assigned to us.
Assist with Patient Safety and Satisfaction
PATIENT IDENTIFICATION BRACELETS:
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Color coded bracelets
o Colored stickers…green=latex allergy, red=allergy
o Pink bracelet=limb alert-do not use limb
High risk for falls (fall bundles)
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Yellow bracelets on patients
Yellow rectangle magnet on door frames, yellow footies, yellow lap blanket.
Hourly rounding is done on all patents and documented in the room, patients are assessed on their needs
to help prevent falls
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Occurrence Reports
If one of the following incidents occur and you are witness to it please report immediately to your on-site
faculty and if faculty is not on-site report to staff, charge nurse, house supervisor, unit director or education
department.
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Breach of department policy, patient injury, delays dealing with anesthesia/surgery/delivery
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Behavioral actions and attitudes dealing with AWOL (Absent without leave), AMA (Against Medical
Advice), violent/agitated behavior or communication problems
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Patient care management problems dealing with consents or patient misidentification
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Complications of diagnosis and/or treatment, delays or omissions of diagnostic tests/procedures
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Falls of patients and/or visitors
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Patient/staff/hospital property missing or damaged
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Medication errors. Incorrect dose/patient/medication/time/route and IV related/pharmacy related errors.
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Incidents occurring when using equipment as in equipment failure, user error, etc.
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Thefts, vandalism or other criminal activity
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“Near Misses” are events that could have caused serious damage to the patient or staff, but were averted
Risk Management
If you are involved in an accident or injured while at Terre Haute Regional Hospital, immediately inform your instructor
and the charge nurse in the area. These individuals will assure that emergency care is instituted as necessary and that the
incident is properly reported.
Abuse and Neglect
At THRH we want to heighten the awareness of abuse and neglect by increasing the staff knowledge of signs and
symptoms and physical indicator of abuse and neglect. Staff who has any suspicions about abuse or neglect of a patient or
staff or even a visitor is required to report their findings to a supervisor or instructor. With Elder abuse the abuse can take
the form of physical, monetary, emotional, abandonment, neglect or sexual abuse. Domestic abuse of any kind needs to
be reported immediately. Any suspicions of child abuse such as mental, physical or emotional abuse must also be reported
as soon as possible. Additional education on the different signs and symptoms of abuse and neglect can be found on eresources or in the Education Department.
2014 National Patient Safety Goals
Identify patients correctly
Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure
that each patient gets the correct medicine and treatment.
Make sure that the correct patient gets the correct blood when they get a blood transfusion.
Improve staff communication
Get important test results to the right staff person on time.
Use medicines safely
Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in
the area where medicines and supplies are set up.
Take extra care with patients who take medicines to thin their blood.
Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking.
Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to
take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they
visit a doctor.
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Use alarms safely
Make improvements to ensure that alarms on medical equipment are heard and responded to on time.
Prevent infection
Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization.
Set goals for improving hand cleaning. Use the goals to improve hand cleaning.
Use proven guidelines to prevent infections that are difficult to treat.
Use proven guidelines to prevent infection of the blood from central lines.
Use proven guidelines to prevent infection after surgery.
Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.
Identify patient safety risks
Find out which patients are most likely to try to commit suicide.
Prevent mistakes in surgery
Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.
Mark the correct place on the patient’s body where the surgery is to be done.
Pause before the surgery to make sure that a mistake is not being made.
Age Specific Competencies
All people from the time of birth to their time of death pass through certain identifiable stages of growth and development.
Health care professionals must be able to distinguish the patients’ needs based on their individual stage of growth and
development. Each patient at all phases has different challenges. We, at Terre Haute Regional Hospital place individuals
into these age groups: neonate, infant, child, adolescent, adult and geriatric. Within these groups we must acknowledge
their ability to assess and interpret data, their own knowledge of growth and development within themselves, our ability to
provide age specific care and our ability to provide age appropriate communication, education and interaction.
CULTURE COMPETENCE
Cultural Competence is the ability of health care providers and organizations to understand and respond effectively to the
cultural and language needs brought by diverse patients to health care encounters. Culture is a set of values shared by a
group of people. It includes their values, beliefs and practices that are passed from generation to generation. Culture
affects all areas of life, including beliefs about health, nutrition, communication, birth and death. Examples of some
cultures include people who are:






Native American – North American Indians or Alaskan natives
Hispanic – from areas such as Spain, Portugal, South America and Central America
African – American – from Africa or the Caribbean countries
Asian – having roots in China, Japan, Korea, or other Asian countries
European – from countries such as England, France, Germany, Italy, or other European countries
Of certain religious faiths – such as Catholic, Protestant or Jewish
Why is Culture Important?
The population of the United States is becoming much more diverse…there are many people of different cultures. This
means that you will often have the opportunity to care for patients who have cultures different from your own. In order to
give them the best care, you must work within their cultural beliefs and practices.
Use these guidelines to provide culturally competent care:
 Treat all patients and families with respect. Call adults Mr. and Mrs. unless asked to do otherwise.
 Never act shocked or make fun of anything the family does, such as “Eww—you really eat that?”
 If English is not their first language, make sure that what you tell them is understood by having them say it back to
you in their own words. Do not ask questions they can answer “yes” or “no”. Some people, especially Asians, may
smile, nod and say, “Yes” to everything. If communication is very difficult, get a translator.
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



Accept and respect their beliefs, even if you don’t agree with them. A Middle Eastern wife may run to meet her
husband’s every need and take orders from him without question.
Realize that people have different beliefs about time. North Americans of European heritage tend to be very futureoriented. They may save money for future retirement and make healthy lifestyle choices now in the hopes of having
good health in the future. But many other cultures, such are more centered on the present. They may not feel it’s
important to be at an appointment or take a medicine at a certain time.
In many cultures, elder members are respected and their life experiences are highly valued. Institutionalization of
elderly family members is avoided at all costs. Family members are expected to provide care and meet the needs of
their elders.
When you respect and appreciate someone’s culture, you show respect for him or her as a person. Your patient is
much more likely to meet his healthcare goals if care is planned in harmony with important cultural beliefs and
practices.

Harassment/Violence in the Workplace
Terre Haute Regional Hospital supports a workplace where everyone is treated professionally, respectfully and is not subject to
harassment. Harassment is unwelcome conduct that creates an intimidating, hostile or offensive work environment that unreasonably
interferes with an individual’s work performance or negatively affects tangible job benefits and is directed at an individual because of
his/her age, disability, national origin, race, color, religion, gender, sexual orientation or veteran status. Sexual harassment includes
sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature.
Report harassment immediately!
Recognizing the Warning Signs of Workplace Violence:



Emotional: Paranoia, manic behavior, disorientation, excitability
Physical: Frequent change of posture, pacing, easily startled, clenching fist, aggressive behavior
Verbal: Claims of past violent acts, loud forceful speech, arguing, making unwanted sexual comments, swearing, threatening
to hurt others, refusing to cooperate or obey policies
Other
 Psychiatric or neurological impairments
 History of threats or violence
 Loss of power or control
 Strong anxiety or grief
 Alcohol or substance abuse
Responding to violence
 Don’t reject all demands outright
 Don’t make false statements of promise
 Do respect personal space
 Don’t bargain, threaten, dare or criticize
 Do keep a relaxed but attentive posture
 Do manage wait times
 Do listen with care and concern
 Do offer choices to provide a sense of control
 Do avoid being alone
 Don’t make threatening movements
 Don’t act impatient
Prevention
 Avoid situations that are potentially unsafe
 Walk to cars in groups or call security for an escort
 Have car keys ready before leaving the building
 Secure belongings
 Do not share personal information with strangers
 Let staff know immediately if you have concerns
Page 18 of 31
Quality Resource Management
Quality is defined as “setting standards of performance which reflect the needs of our internal and external customers. Our
commitment to quality is written in our mission and shown through our daily actions.” Some of the components of quality
include:
*Medical Staff Credentialing/Clinical Monitoring/Physician’s Relations review & Quality monitoring for focused
& ongoing professional practice evaluations;
*Performance Improvement is completed to make systems &/or processes better for our customers; the
methodology utilized for data collection is called PDCA (Plan Do Check Act) and is adopted by The Joint Commission
for monitoring performance improvement activities;
*National Patient Safety Goals (NPSGs) are updated annually by The Joint Commission and are in place to focus
on improving patient safety. (www.jointcommission.org);
*Policies and orders sets are reviewed at least every 3yrs (if the policy is related to Lab functions then it is
reviewed at least every 2yrs). All policies and order sets must meet State/Federal & TJC guidelines and are monitored
through an approval process;
*Error Reporting is encouraged for all events and near misses. Completing an occurrence report is non-punitive.
Should a medical error occur members of the Administrative Team & Risk Management will notify the patient&/or family
members. Some events must be reported to the Indiana Medical Error Reporting System and to the Joint Commission;
*A Sentinel Event is an unexpected occurrence involving death or serious physical or psychological injury or
risk thereof (an event that results in unanticipated death or major permanent loss of function not related to the natural
course of the patient’s illness or underlying condition.) All Sentinel Events are reported to The Joint Commission and a
Root Cause Analysis is completed; if a “near miss” occurs an intensive analysis is completed to review processes and
implement action plans for patient safety;
*Core Measures are diagnoses and/or procedures which have evidence driven interventions or practices.
Implementation of the evidence driven practices have been shown to positively impact a patient’s mortality and/or
morbidity. The Joint Commission recognized Terre Haute Regional Hospital as being a Top Performing Hospital in the
nation based on 2013 data. To review quality scores go to www.hospitalcompare.com and compare hospitals anywhere in
the nation.
Joint Commission Standards
What is The Joint Commission?



The Joint Commission “accredits” health care
organizations, such as hospitals.
We visit organizations to make sure they meet
our standards of care.
Organizations that meet our standards are
accredited for three years. After three years,
we go back to the organization to make sure it
still meets our standards.
Page 19 of 31
Student Competencies/Information
Infant Security:
Infant and child security is of upmost importance. The 2 nd floor has secure doors and units for patient’s safety. All infants have a
security alert bracelets placed on them at the time of birth. Staff and visitors attempting to use elevators and exits on the second floor
must receive access by staff members of the 2nd floor.
IV / Medication Administration:
IV and IV therapy education/competency including the proper usage of the Alaris IV Pumps are the responsibility of the clinical
institution and/or instructor. Additional education and resources are available by contacting the Education Department of THRH.
Students, with their instructors, must verify physicians order, remain free of distractions, and utilize the right patient, right dose, right
route and right drug with each medication they administer. Patients shall be identified using 2 unique identifiers and whenever
possible the EMAR scanning system should be utilized. Students my administer medication based on the curriculum of their
individual clinical program but only instructors will be given access to the Pyxis and the EMAR administration record.
Controlling Pain
Untreated pain can cause increase oxygen consumption, hypercoagulability, inadequate sleep, tachycardia, hypertension,
immunosuppression, and persistent catabolism. Patients with chronic pain could go through withdrawal if home medication
treatment is not continued. Based on the patient’s condition and assessed needs, the education and training provided to the patient
by the hospital should include the following: Discussion of pain, the risk for pain, the importance of effective pain management, the
pain assessment process, and methods for pain management.
MEWS / AVPU System and Neuron use:
Some nursing units utilize the Vitals Now Neuron to measure and document patient vital signs and level of consciousness. Students
must be able to demonstrate competency to their instructor on the proper use of the Vitals Now Capsule. Students must scan the
patients arm band and verify each patient using 2 identifiers. Trouble shooting, documenting and reviewing of documentation will be
reviewed with you. MEWS is a modified early warning system that we use in documenting AVPU (Alert, responsive to Voice,
responsive to Pain, and Unresponsive) as part of our assessments of our patients. This system is in place to notify health care
representatives when a patient’s condition has changed. Any change of more than 2 point in a MEWS score or a score of 5, a condition
C should be called to assist with patient care.
Blood Glucose Monitoring:
All students that are permitted to use Terre Haute Regionals Blood Glucose Monitoring system will be given education and
competency during their 1st day of clinical by the Education Department and/or their clinical instructor.
Meditech Documentation:
All Meditech documentation by a student will be under those students individual ID and password issued during their specific clinical
rotation by the IT&S Staff at THRH. The clinical instruction must review all charting done by the students and document so.
Patient Education/Teach Back:





Asking the patient/key learner to recall and restate in their own words what they thought they heard during the education
Asking the patient/key learner to explain or demonstrate how they will undertake a recommended treatment or intervention
40 – 80% of information that the patient receives during hospitalization is forgotten immediately after delivery
Almost half of information is remembered incorrectly
The more information given, the more information forgotten
Page 20 of 31
Shift Hand off Communication:


Bedside shift handoff should be done on ever patient, from nurse to nurse, student nurse to student nurse and tech
to tech or any combination.
Make sure to pass on all important information including medication, missed or new orders, changes in patient
condition, upcoming test/procedure or any education needed or provided.
DEPARTMENT SPECIFIC EXPECTATIONS/REQUIREMENTS
All Areas:
•
Do not come to department without your identification badge on.
•
Be professional.
•
Be prepared: pen, paper, stethoscope (if nursing).
•
Ask questions, do not stand at desk and expect to learn.
PARKING
Every student must follow
our facility parking
guidelines. These
guidelines insure enough
parking for all who need
access to Terre Haute
Regional services at any
given time of the day. If
you are here for a clinical
rotation, you must park in
the far lot behind the
emergency entrance, the lot
to the side of the Regional
Pavilion building. Failure to
park in designated parking
could result in disciplinary
action.
Park in Yellow Areas
ONLY
Page 21 of 31
Fire/Evacuation Safety:
*7112
2
Page 22 of 31
Form A
Terre Haute Regional Hospital IT&S Security Access Form
Applicant Last Name
Applicant First Name
Applicant M I or " NA"
Work Address
Terre Haute Regional Hospital
Applicant Work Phone Number
3901 South 7th Street
Applicant date of birth
Applicant Social Security Number
Facility COID and Facility Number
Facility Name
31408
Terre Haute
Indiana 47802
Applicant work email address if known
00097
Applicant birthplace
M aiden name of applicant's mother
Facility Type
Terre Haute Regional Hospital
Department number
Department Name
Applicant Universal ID
Lawson Job Code and description if known
Division
Hospital
Capital
Domain
HCA
Applicant job title
Applicant Signature
Date of Applicant Signature
Authorizing Security Coordinator Statement
By signing this request I am stating that I have reviewed the above information for completeness and it is accurate to the best of my knowledge. Also I have reviewed the Information Security
Agreement and verified that it has been completely filled out and signed. Also that I verify this request and authorize its processing
M anagers Signature
M anagers Printed Name
Date of Signature
Security Coordinators Signature
Security Coordinators Printed Name
Date of Signature
Action:
New
Change
Delete
Effective Date:
Accudose RX Access
Pyxis Connect
HPF Describe access needed:
Other Access: provide description: _______________________________________
Student Nurse
Questions regarding this form? Please call HDIS & FISO at 812-237-1171
Attach a Copy of your Driver’s License
Page 23 of 31
Form B
Confidentiality and Security Agreement
Note: this form to be used for HCA employees and HCA workforce members.
I understand that the HCA affiliated facility or business entity (the “Company”) for which I work, volunteer or provide services manages
health information as part of its mission to treat patients. Further, I understand that the Company has a legal and ethical responsibility to
safeguard the privacy of all patients and to protect the confidentiality of their patients’ health information. Additionally, the Company
must assure the confidentiality of its human resources, payroll, fiscal, research, internal reporting, strategic planning information, or any
information that contains Social Security numbers, health insurance claim numbers, passwords, PINs, encryption keys, credit card or other
financial account numbers (collectively, with patient identifiable health information, “Confidential Information”).
In the course of my employment/assignment at the Company, I understand that I may come into the possession of this type of
Confidential Information. I will access and use this information only when it is necessary to perform my job related duties in accordance
with the Company’s Privacy and Security Policies, which are available on the Company intranet (on the Security Page) and the Internet
(under Ethics & Compliance). I further understand that I must sign and comply with this Agreement in order to obtain authorization for
access to Confidential Information or Company systems.
General Rules
1.
I will act in the best interest of the Company and in accordance with its Code of Conduct at all times during my relationship
with the Company.
2.
I understand that I should have no expectation of privacy when using Company information systems. The Company may log,
access, review, and otherwise utilize information stored on or passing through its systems, including email, in order to
manage systems and enforce security.
3.
I understand that violation of this Agreement may result in disciplinary action, up to and including termination of
employment, suspension, and loss of privileges, and/or termination of authorization to work within the Company, in
accordance with the Company’s policies.
Protecting Confidential Information
4.
I will not disclose or discuss any Confidential Information with others, including friends or family, who do not have a need to
know it. I will not take media or documents containing Confidential Information home with me unless specifically authorized
to do so as part of my job.
5.
I will not publish or disclose any Confidential Information to others using personal email, or to any Internet sites, or through
Internet blogs or sites such as Facebook or Twitter. I will only use such communication methods when explicitly authorized
to do so in support of Company business and within the permitted uses of Confidential Information as governed by
regulations such as HIPAA.
6.
I will not in any way divulge copy, release, sell, and loan, alter, or destroy any Confidential Information except as properly
authorized. I will only reuse or destroy media in accordance with Company Information Security Standards and Company
record retention policy.
7.
In the course of treating patients, I may need to orally communicate health information to or about patients. While I
understand that my first priority is treating patients, I will take reasonable safeguards to protect conversations from
unauthorized listeners. Such safeguards include, but are not limited to: lowering my voice or using private rooms or areas
where available.
8.
I will not make any unauthorized transmissions, inquiries, modifications, or purgings of Confidential Information.
9.
I will not transmit Confidential Information outside the Company network unless I am specifically authorized to do so as part
of my job responsibilities. If I do transmit Confidential Information outside of the Company using email or other electronic
communication methods, I will ensure that the Information is encrypted according to Company Information Security
Standards.
Following Appropriate Access
10. I will only access or use systems or devices I am officially authorized to access, and will not demonstrate the operation or
function of systems or devices to unauthorized individuals.
11. I will only access software systems to review patient records or Company information when I have a business need to know,
as well as any necessary consent. By accessing a patient’s record or Company information, I am affirmatively representing to
the Company at the time of each access that I have the requisite business need to know and appropriate consent, and the
Company may rely on that representation in granting such access to me.
Using Portable Devices and Removable Media
12. I will not copy or store Confidential Information on removable media or portable devices such as laptops, personal digital
assistants (PDAs), cell phones, CDs, thumb drives, external hard drives, etc., unless specifically required to do so by my job. If
Page 24 of 31
I do copy or store Confidential Information on removable media, I will encrypt the information while it is on the media
according to Company Information Security Standards
13. I understand that any mobile device (Smart phone, PDA, etc.) that synchronizes company data (e.g., Company email) may
contain Confidential Information and as a result, must be protected. Because of this, I understand and agree that the
Company has the right to:
a.
Require the use of only encryption capable devices.
b.
Prohibit data synchronization to devices that are not encryption capable or do not support the required security
controls.
c.
Implement encryption and apply other necessary security controls (such as an access PIN and automatic locking) on
any mobile device that synchronizes company data regardless of it being a Company or personally owned device.
d.
Remotely "wipe" any synchronized device that: has been lost, stolen or belongs to a terminated employee or
affiliated partner.
e.
Restrict access to any mobile application that poses a security risk to the Company network.
Doing My Part – Personal Security
14. I understand that I will be assigned a unique identifier (e.g., 3-4 User ID) to track my access and use of Confidential
Information and that the identifier is associated with my personal data provided as part of the initial and/or periodic
credentialing and/or employment verification processes.
15. I will:
a.
Use only my officially assigned User-ID and password (and/or token (e.g., SecurID card)).
b.
Use only approved licensed software.
c.
Use a device with virus protection software.
16. I will never:
a.
Disclose passwords, PINs, or access codes.
b.
Use tools or techniques to break/exploit security measures.
c.
Connect unauthorized systems or devices to the Company network.
17. I will practice good workstation security measures such as locking up diskettes when not in use, using screen savers with
activated passwords, positioning screens away from public view.
18. I will immediately notify my manager, Facility Information Security Official (FISO), Director of Information Security
Operations (DISO), or Facility or Corporate Client Support Services (CSS) help desk if:
a.
my password has been seen, disclosed, or otherwise compromised;
b.
media with Confidential Information stored on it has been lost or stolen;
c.
I suspect a virus infection on any system;
d.
I am aware of any activity that violates this agreement, privacy and security policies; or
e.
I am aware of any other incident that could possibly have any adverse impact on Confidential Information or
Company systems.
Upon Termination
19. I agree that my obligations under this Agreement will continue after termination of my employment, expiration of my
contract, or my relationship ceases with the Company.
20. Upon termination, I will immediately return any documents or media containing Confidential Information to the Company.
21. I understand that I have no right to any ownership interest in any Confidential Information accessed or created by me during
and in the scope of my relationship with the Company.
By signing this document, I acknowledge that I have read this Agreement and I agree to comply with all the terms and conditions
stated above.
Employee/Workforce Member/ Student Signature
Facility Name and COID
Employee/Workforce Member/ Student Printed Name
Business Entity Name
Date
Page 25 of 31
FORM C
STATEMENT OF RESPONSIBILITY
For and in consideration of the benefit provided the undersigned in the form of experience in a clinical setting at
Terre Haute Regional Hospital ("Hospital"), the undersigned and his/her heirs, successors and/or assigns do hereby
covenant and agree to assume all risks and be solely responsible for any injury or loss sustained by the undersigned
while participating in the Program operated by:
("School") at Hospital unless such injury or loss
arises solely out of Hospital's gross negligence or willful misconduct.
Signature of Program Participant
Date
Printed Name
Parent or Legal Guardian
If Program Participant is under 18 / Print Name
Date
Page 26 of 31
FORM D
Terre Haute Regional Hospital
POLICY AND PROCEDURE
TITLE: Parking Guidelines
DEPARTMENT/SCOPE: Administrative / Facility Wide
Page 27 of 31
REPLACES POLICY DATED: 5/09
ORIGINAL DATE: 2/2009
REVIEWED OR REVISED: 5/09, 1/11, 9/11
REFERENCE NUMBER: ADM.HR.053
PURPOSE:
To identify the appropriate parking area for employees, patients, visitors, and physicians.
To list the consequences for violation of this policy.
POLICY:
Terre Haute Regional Hospital shall make available adequate parking for handicapped individuals and to comply
with all state and federal laws, rules, regulations, and standards including the Americans with Disabilities Act.
Individuals with valid handicapped license plates or permits appropriately displayed in their cars may park in
designated handicapped parking spaces located around the hospital campus.
Parking is not permitted on curbing along the hospital and the office buildings. This curbing is painted yellow.
Parking is restricted from the back dock area. Parking is restricted in the drive-through areas of all main
entrances.
PROCEDURE:
1. Employees
A. All employees are to park in designated parking areas. Refer to Attachment A.
B. Employees, students, and physicians will be provided with parking passes for their vehicles. All affiliates
must be responsible for maintaining their parking stickers, and must display them in the window of the
vehicle at all times. Failure to do so will result in disciplinary action as outlined in Section III. Parking
stickers may be obtained from the Human Resources Department.
C. Volunteers may park in visitor’s parking lots to accommodate those unable to walk long distances.
D. Employees and students may park in the designated handicapped parking areas with valid license plates or
permits issued from their state’s Department of Motor Vehicles. Use of a family member’s license plate or
permit is prohibited.
2. Physicians: Physicians are to park in the gated lot on the southeast part of campus and in designated
locations marked for physician parking.
3. Violations
A. Terre Haute Regional Hospital Security reserves the right to tow any vehicle at any time found to be parked
in an inappropriate area.
B. If parked inappropriately, employees and affiliates will be asked to clock out and move their vehicle to an
approved area. Employees parking in wrong/non-designated employee parking areas will be subject to
disciplinary actions to include termination.
REFERENCE:
American Disabilities Act of 1990
Page 27 of 31
Form D (page 2)
TITLE: Parking Guidelines
REFERENCE NUMBER: ADM.HR.053
Page 28 of 31
Parking Guidelines Policy Acknowledgement
I have read the parking guidelines policy and understand my responsibility to comply with the guidelines in
order to provide adequate parking for our customers and visitors. I understand that my failure to comply with
the guidelines will result in disciplinary action as outlined in section III of the policy. I understand that I must go
to Human Resources on my 1st clinical day and get a parking pass and place it in the front dashboard of my
vehicle.
Printed Name: __________________________________________
Signature:
_____________________________________________
School: _______________________________________________
Date: __________________________________________________
Page 28 of 31
Form E
HIPAA Privacy, Security and Appropriate Access Quiz
Print Name:
Date:
School:
Instructions: Please answer each question by circling the correct answer and return it to the: EDUCATION DEPARTMENT
1.
True or False: HITECH stands for Health Information Technology for Economic and Clinical Health Act.
2.
Confidential Information includes all of the following except:
a. Patient Financial Information
b. User ID
c. Passwords
d. Clinical Information
3.
Individually identifiable health information may NOT be:
a. Faxed
b. Mailed
c. Sold
4.
Who is responsible for protecting patients’ individually identifiable health information?
a. CEO
b. ECO
c. Physician
d. All of the above
e. None of the above
5.
It would be appropriate to release patient information to:
a. The patient's (non-attending) physician brother
b. The transferring hospital’s personnel checking on the patient
c. The respiratory therapy personnel doing an ordered procedure
d. A retired physician who is a friend of the family
6.
True or False: If a person has the ability to access facility or Company systems or applications, they have a right to view any information contained
in that system or application?
7.
A patient listing given to a member of the clergy should be restricted by religion and may have the following information except:
a. Patient name
b. Patient Social Security Number
c. Patient location
d. Patient condition in general terms
8.
Which of the following is the appropriate person with whom to share patient information even if the patient has NOT specifically authorized the
release of information to the individual:
a. A former physician of the patient who is concerned about the patient
b. A colleague who needs information about the patient to provide proper care
c. A friend of the patient
d. A pharmaceutical salesman who is offering a fee for a list of patients to whom he could send a free sample of his product
9.
The acronym for HIPAA stands for:
a. Health Information Protection and Accountability Act
b. Health Insurance Portability and Accountability Act
c. Health Information Publication and Accumulation Act
d. None of the Above
10. True or False: It is part of our jobs to learn and practice the many ways we can help protect the confidentiality, integrity and availability of electronic
information assets.
11. True or False: With limited exceptions, patients have a right to access their health information.
12. What is the standard for accessing patient information?
Page 29 of 31
a.
b.
c.
d.
A need to know for the performance of your job
If a physician asks you the diagnosis of the patient
Just because you are curious
You are a relative of the patient
13. Yes or No: Should you access your own medical record via the Meditech system?
14. If an employee has medical testing at an HCA facility, the appropriate way for him or her to access the test results is:
a. Complete the release of information form in HIM and receive a copy of the results
b. Check the computer system for his or her own results
c. Get a fellow employee to access the results while looking over his or her shoulder
d. Call a friend in the department where the test was done to get the results for the employee
15. True or False: Patient or confidential information may be sent through email or the Internet with guaranteed security.
16. When a HITECH breach occurs, the facility must notify which of the following entities?
a. The patient, the Department of Health and Human Services, and the Centers for Medicare and Medicaid Services
b. The patient, the attending physician, and the Department of Health and Human Services
c. The patient, the Department of Health and Human Services, and in some cases, the media
d. The patient, the Centers for Medicare and Medicaid Services, and in some cases, the media
17. True or False: Individual workforce members could face criminal penalties related to violations of patient privacy.
18. A patient tells her nurse that she does not want her information used by the hospital in any way except for treatment purposes. The nurse should:
a. Agree to the request and notate the medical record
b. Explain to the patient that it is not possible to restrict her information
c. Agree to the request and notify the facility privacy official at the end of the nurse’s shift
d. Advise the patient that the request must be made in writing to the facility privacy official
19. Patient information is considered individually identifiable if which of the following elements are included:
a. Social Security Number
b. Name
c. Fingerprint
d. All of the above
20. True or False: Patients need to sign a form acknowledging receipt of the facility’s Notice of Privacy Practices.
21. True or False: Only clinicians may access a patient’s health information.
22. Under the privacy rule each facility must designate _________________ who is responsible for the development and implementation of privacy
policies and procedures for the facility.
a. A Facility Privacy Official
b. A privacy watch Officer
c. An Ethics and Compliance Officer
d. A mediator
23. A visitor who asks for a patient by name may receive the following information except:
a. Patient name
b. Patient condition in general terms (e.g. stable, critical, etc.)
c. Patient location
d. Patient diagnosis
24. True or False: Copies of patient information may be disposed of in any garbage can in the facility.
25. True or False: It is permissible to discuss a patient on a social networking site (e.g., Facebook, Twitter) as long as the patient’s name is removed.
I attest that I have read the HIPAA training slides that cover HIPAA training for students. I attest that the training included: (i) Information on HIPAA
Terminology; (ii) Facility Name Pass Code policy; (iii) the “Need to Know” concept and understands what it means; (iv) proper disposal of PHI; (v) how to
correctly fax information that relates to patient care; (vi) how to report a privacy violation; (vii) what it means when a patient “Opts Out” of the directory;
and that I may not access my own medical record.
STUDENT SIGNATURE & DATE: _______________________________________________________
GRADED BY: _____Carrie Deakins RN, BSN ____________________
Any patient has the right to complain about a Privacy Violation.
Page 30 of 31
Form F
Attestation of Student Orientation Book
On behalf of_______________________________(Name of School) , I acknowledge and attest to Terre
Haute Regional Hospital that I _______________________________ (Printed Name) as an instructor/student
of the above listed school, has reviewed the THRH Student Orientation Book with my oncoming students and I
have send the required paperwork to the Education Department at Terre Haute Regional Hospital.
I further understand that I will be attending clinical at Terre Haute Regional and are responsible for the
information listed in the book. I understand that this orientation is good for the period of one (1) year from the
date signed.
(Student Signature)
(Student Printed Name)
(School / Class / Instructor)
(Summer / Spring / Fall)-circle one
(Date Signed)
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