Penn State Emergency Medical Services

Penn State EMS Standard Operating Procedures and Constitution

University Ambulance Service
Centre County Company 20
Procedures Manual

ADMINISTRATIVE FORMS

TABLE OF CONTENTS

Request for Professional Development

Conference Room Request

Confidential Report to Improve Quality of Services (CRIQS)

Confidentiality Statement

Employer's Report of Occupational Injury or Disease

Internship/Practicum/Independent Study Contract Proposal

Property Damage and Non-Employee Incident Report

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REQUEST FOR PROFESSIONAL DEVELOPMENT

Purpose:

With the signature of the Director, this form authorizes payment of registration and
travel expenses incurred, according to PSU policy, while attending conferences or
workshops.

This form also authorizes attendance at a professional development activity when
no expenses will be incurred.

Where to Obtain Forms:

Request for Professional Development forms may be obtained from the Staff
Assistant in the Director' s office (216) or the Purchasing Staff Assistant in the
Business Office, or the Office of Health Promotion and Education.

Where to Send Completed Forms:

After the individual who is attending the conference completes all applicable items,
the form is reviewed and signed by the Department Head who in turn sends the
form to the Director' s Office for approval. After approval by the Director, if expenses
are to be incurred, the form will be routed to the Purchasing Staff Assistant and the
Office of Health Promotion and Education to process. If no expenses are incurred,
the form is returned to the supervisor, employee and the Office of Health
Promotion and Education.

Instructions:

1. Complete the form for all continuing education experiences offered outside of
UHS, whether expenses are to be incurred or not.

2. Fill in all items completely which pertain to your specific travel needs.

3. Be sure you have entered the best Total Cost estimate.

4. Attach the information brochure and completed original registration form.

5. Obtain the required signatures/approvals.

6. While planning for your travel expenses, please remember to keep all necessary
receipts for reimbursement on your return.

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CONFERENCE ROOM REQUEST FORM

Purpose:

This form is to be used to reserve a Ritenour Building conference room and to
request food/beverages for meetings.

Where to Obtain Forms:

107 Ritenour

Where to Send Completed Form:

Reception Staff Assistant in 107 Ritenour

Instructions:

Complete Date Requested, Room Requested (16 or 28), Time (beginning and ending
time of program/meeting), Name of Program, Requested By and the Date requested.
Check off any A-V equipment needs. A TV and VCR are always available in Rooms
16 and 28. Indicate the Room Set-Up Requirements and list Number of Attendees.
Indicate Food/Beverage needs and the Number of Attendees. UHS only provides
beverages for meetings in Rooms 16 and 28. Lunch is only provided for mandatory
noon-time meetings.

Upon receipt of the form, the Reception Staff Assistant will complete the
confirmation portion of the request and return a copy to the requestor. She will send
a copy to the facilities staff.

Any cancellations or changes should be reported to the Reception Staff Assistant (5-
6556) and to the Facilities Staff (5-7702) as soon as possible.

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CONFIDENTIAL REPORT TO IMPROVE QUALITY OF SERVICES (CRIQS)

Purpose:

The CRIQS form is used to document any out of ordinary events which occur at
UHS involving staff, clients, and/or visitors for the purposes of reporting,
documenting and monitoring the occurrence of these events. This documentation
is used to assist in the identification of quality improvement and risk management
problem identification and resolution.

Where to Obtain Form:

Primary Care Staff Assistant, 209 Ritenour

Number of Copies and Distribution:

Instruction page
3 copies - original and 2 carbon copies

Where to Send Completed Form:

Manager for Quality Improvement, 208 Ritenour

Instructions:

1. "Out of ordinary events" include but are not limited to:
     - On the job injuries
     - Visitor injuries occurring within UHS
     - Medication errors
     - Inquiries from legal counsel
     - Patient complaints
     - Patient injuries occurring within UHS
     - Apparent theft of equipment from UHS
     - Allergic drug reactions

2. As soon as possible afterward the individual who "discovers," is involved in or
witnesses the out of ordinary event completes the form as appropriate for the
incident being reported.

3. The form (all 3 copies) is sent to the Manager for Quality Improvement (MQI).

4. The design of the form deletes the sections on the carbon copies which identify
the individual completing the form and the individual about whom the form is
written.

5. The MQI reviews the form and sends the carbon copy page(s) describing the
incident to department supervisor(s) for follow-up.

6. The original copy is kept in a locked file in the MQI' s office and is destroyed after
6 months.

READ AND DETACH THIS PAGE BEFORE COMPLETING REPORT
CONFIDENTIAL REPORT GUIDELINES

Completion of this report is not punitive in nature but is done in the interest of
improving the quality of our services.


ATTENTION: These reports are PRIVILEGED DOCUMENTS, NOT available for use
in litigation.
To protect this privilege:

1. Never show it to unauthorized persons.
2. Never mention it in the medical record.
3. Never photocopy the completed report.


A CONFIDENTIAL REPORT SHOULD BE COMPLETED IF ANY OF THE
FOLLOWING OCCURS:

1. Any event which you identify as an out-of-the-ordinary occurrence or untoward
event (be specific with scope of statement).

2. Medical or nursing care or treatment resulting in an expression of a complaint or
dissatisfaction by the patient or family member.

3. Circumstances or conduct that injured or could have injured a patient / client,
visitor or staff member, including patient falls.

INCIDENT REPORT CONTENTS:

1. Summarize the "DETAILS OF EVENT" using the following guidelines: A.
Describe events chronologically. B. List relevant facts concisely. C. Quote relevant
statements made by patients or others. Describe the attitudes of individuals if
relevant. D. Specify brand name and location of product / equipment involved in
incident (if relevant). E. Specify name and title of person(s) who were involved in or
witnessed the incident. Such information MUST be included for meaningful
evaluation and analysis. F. Use the back of page one if necessary. G. In the event of a
physical injury, a clinician should be notified. Falls: In the event of a fall, please
record the following: Person attented or not Location If appropriate, bed rails up or
down Bed high or low Whether or not x-ray ordered.

2. Complete "MEDICATION / IV ERRORS ONLY" if appropriate.

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CONFIDENTIALITY STATEMENT


Purpose:

This form is signed by all employees, volunteers, practicum students who work at
UHS. The purpose of this form is to explain UHS' s confidentiality policy and to
document that the individual has had the policy and the consequences of its
violation explained by his/her supervisor.

Where to Obtain Form:

Primary Care Staff Assistant, 209 Ritenour.

Number of Copies and Distribution:

One - original - sent to department supervisor who obtains individual' s signature

Where to Send Completed Form:

Primary Care Staff Assistant, 209 Ritenour

Instructions

1. Upon notification of the arrival of a new employee, volunteer, practicum student,
the Primary Care Staff Assistant sends the form to the individual' s supervisor.

2. Supervisor is requested to have individual sign form after supervisor explains
confidentiality policy.

3. Supervisor signs and dates the form as the witness.

4. Supervisor returns signed form to the Primary Care Staff Assistant.

5. Form is filed in the Primary Care Staff Assistant' s office.

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UNIVERSITY HEALTH SERVICES
STATEMENT OF CONFIDENTIALITY

   In the performance of your duties and responsibilities at University Health
Services, you are expected to maintain and protect the confidentiality of patient
information.  Confidential patient information may be released only with the
patient's written authorization, by court order or as otherwise mandated by law.

Confidential Patient Information includes but is not limited to:

1. Patient Name and other information obtained upon admission or registration at
medical records, outpatient department, observation unit and urgent care clinic;

2. All case discussions, diagnoses, consultations, examinations, and treatments;

3. All forms of patient records and copies of orders;

       and

4. All information about the disposition or personal characteristics of patients.

   Any breach of your duty to maintain and protect the confidentiality of patient
information, including the unauthorized release of confidential information to
third parties, may subject you to disciplinary action including dismissal.


I acknowledge receipt of the University Health Services' "Statement of
Confidentiality."


Signature	Date


Name (please print)


Witness	Date

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EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR DISEASE

Purpose:

This University form is used to report on-the-job injuries to the UHS Risk
Management Coordinator and ultimately the University' s Worker' s
Compensation Carrier and the Bureau of Worker' s Compensation.

Where to Obtain Form:

Primary Care Staff Assistant, 209 Ritenour

Number of Copies and Distribution:

Original	White	Risk Management
1st Carbon	White	"	
2nd Carbon	White	"
3rd Carbon	White	"
4th Carbon	Salmon	"
5th Carbon	White	Employee

Where to Send Completed Form:

The first five forms in the packet are to be sent to the University Risk Management
office. The last copy, "Injured Employee' s Copy" is given to the injured employee
immediately upon completion of the packet.

Instructions:

1. UHS employee completes a "work" copy of this form and sends it to the UHS Risk
Management Coordinator (RMC), 208 Ritenour.

2. The University multi-copy form is prepared by the Primary Care Staff Assistant
and sent to the employee' s supervisor for review and signature.

3. The completed form is sent by the UHS RMC to the Student Affairs Safety Officer
who sends the form to the Risk Management Office.

4. A photocopy of the form is kept in a locked file in the UHS RMC's Office.

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INTERNSHIP/PRACTICUM/INDEPENDENT STUDY CONTRACT PROPOSAL

Purpose:

The purpose of this form is to present for approval and assure good communication
regarding an internship/practicum or independent study undertaken at University
Health Services.

Where to Obtain Form:

Forms are available from the OHPE staff assistant in room 237. The original will be
kept in the Office of Health Promotion and Education, room 237, as well.

Number of Copies and Ultimate Distribution:

Once approved and signed, four copies should be made of this proposal. Copies
should be distributed to the student, internship supervisor, academic department,
and the University Health Services Director. In the case of another UHS
collaborator, that person should receive a copy of the proposal as well.

Instructions:

1. Form should be completed by student in collaboration with UHS staff member
supervising the internship. Both should sign the agreement.

2. Form should then be submitted to the Director, University Health Services, for
her review and signature and the student' s academic advisor.

3. Copies to be made for the intern, the UHS internship supervisor, the Director of
University Health Services and the Academic Department granting the course credit
for the internship/practicum/independent study.

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PROPERTY DAMAGE & NON-EMPLOYEE INCIDENT FORM

Purpose:

The purpose of this PSU form is to document the details of an incident occurring on
campus (specifically in UHS) which results in a physical injury to a non-employee.

Where to Obtain Form:

Primary Care Staff Assistant, 209 Ritenour

Number of Copies and Distribution:

One - original

Where to Send Completed Form:

UHS Risk Management Coordinator, 208 Ritenour

Instructions

1. The form is completed by a UHS staff person familiar with the incident in
consultation with the injured individual.

2. The completed form is sent to the UHS Risk Management Coordinator who sends
it to the PSU Office of Risk Management.

3. A copy of the form is kept in a locked file in the UHS Risk Management
Coordinator's office.