Facility Site Review Policies & Procedures
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Scoring sheets and guidelines:
Site Review Guidelines
Site Review Scoring Sheet
Medical Record Review Guidelines
Medical Record Review Scoring Sheet
Letter to the Provider
1. Access and Safety
A. Earthquake and Fire Emergency Office Procedures
B. Earthquake Pamphlet from California State Office of Emergency Services
2. Personnel
A. Medical Assistant – Training & Scope of Practice Policy - Form
B. Nurse Midwife – Policy
C. Physician’s Assistant - Policy
D. Nurse Practitioner – Policy
E. MD-PA Supervision – Policy
F. Personnel Orientation/Training Checklist
G. Domestic/Elder/Child Abuse Reporting Guide & Forms
H. Emergency Numbers Domestic Violence (Santa Cruz)
I. National Sexual Assault Online Hotline
1. Additional Abuse & Domestic Violence Resources
J. Santa Cruz, Monterey County, Merced County abuse resources
1. Santa Cruz; Monterey County
2. Merced County
K. Child and Adult Protective Services contact Information
1. Adult and Child Protective Services contact information
2. Report of suspected Elder or Dependent Adult – Form
3. Screening and Documenting suspected Domestic Abuse
4. Complaint Form – MediCal Fraud and Elder Abuse
L. Member’s Rights – English & Spanish
M. Confidentiality Statement - Forms
N. Grievance/Complaint Guidelines
Please contact your Provider Services Representative for the most
up-to-date information.
O. Sensitive Services Summary
P. Minor’s Rights Statement & Documentation
of Self-Sufficient Minor Status - Form
3. Office Management
A. Process for Emergencies During & After Hours
B. Telephone Triage Policy
C. Telephone Advice Guidelines
D. Accessibility - Appointments and Scheduling Policy
E. Missed Appointment and Patient Recall Policy
F. After Hours Availability Policy
G. Interpreter Services Policy
H. Medical Interpretation Information
I. Interpreter Services Quick Reference Guide
J. 12 Tips to Working with an Interpreter
K. Referral Tracking Log - Form
L. Treatment Authorization Request (TAR) Policy
M. Referral Authorization Form (RAF) Policy
N. Out of Area (OOA) Policy
4. Clinical Services
A. Pharmaceuticals Storage, Handling and Dispensing Guidelines
B. Drug Expiration Log - Form
C. Master DEA List - Form
D. Controlled Drug Inventory - Form
E. Refrigerator/Freezer Log - Form
5. Preventive Services
A. PCP Quality Improvement Reminders
B. Adult Preventive Care Policy (2010 schedule included in policy)
C. Summary of Recommendations for Adult Immunizations
D. Adult Immunization Wallet Card
E. Adult Vaccination Record Sheet
F. Childhood Preventive Care Policy (2010 schedule included in policy)
G. Alliance Well Child Schedule
H. Summary of Recommendations of Child Immunizations
I. Child California Immunization Record (yellow card)
J. Child/Teen Vaccination Record Sheet
K. Vaccines for Children Information
L. Vaccine Code List - MediCal
M. VIS information and instructions
N. VIS sheets for Flu 2008-2009 Spanish/English
a. VIS Patient Info Sheet - English
b. VIS Patient Info Sheet - Spanish
O. Current VIS dates for Immunizations
6. Infection Control
A. Bloodborne Pathogens Training Program
1. Training Packet
2. Answer Key
B. Biohazardous Waste Disposal Guidelines
C. Autoclave and Cold Sterilization Guidelines
D. Autoclave Run Log - Form
E. Spore Testing for Autoclaves Procedure
F. Sharps Injury Log - Form
7. Medical Records
A. Medical Records Policy
B. Common Medical Record Deficiencies
C. Pre-Review Chart Survey Check List
D. Signature Page - Form
E. 120 Day Assessment Policy
F. Informed Consent
1. Provider’s Office Policy
2. CCAH Policy (for Sterilization)
G. IHEBA - Individual Health Education Behavioral Assessment Forms
1. SHA Information Page
2. SHA Order Form
H. Advance Health Care Directive in English and Spanish, information and
chart documentation - Form
1. Form 1 – English
2. Form 1 – Spanish
3. Form 2 – English
4. Form 2 – Spanish
I. WIC Program Guidelines