Policies and Procedures in Medicine Proposal

Introduction

Policies and procedures are imperative because they govern the functioning of an organization or a facility. Therefore, all staff should access them. Additionally, the health care professionals should receive training about their responsibilities and duties concerning the policies and procedures implementation. Below are sample policies and procedures for the chemical dependency clinic.

Patients Admission

Every new patient must be registered in the admission register.

Patients on follow-up must be registered in the follow-up register.

Every patient who has been referred must have his or her information documented in the referral register.

The medical records

The patients, as well as the staff, must be aware of the confidentiality of clinical records and the information in them.

The staff must not share the information with any other person who is not involved in the management of the patient.

The information about the patient must be private as well as confidential.

Every patient must have his or her own record. The information in the record must include the name, registration number, age, sex, height, history, vital signs as well as diagnosis.

The records must be filed according to the legal requirements of records keeping of a specific country. Additionally, the records must be stored for seven years after the last year of active use of the records.

The person keeping the records must periodically review them for quality control.

The healthcare worker who has ever provided care to the patient must be given permission to access the patient’s record for defense in any allegations against him.

The description of the services

This policy necessitates that the health care professionals must develop a preliminary service plan that describes the kind of services that the patients will receive.

• The focus of the chemical dependency clinic
• The health of the clients

The dependency clinic must provide comprehensive and holistic services that concentrate on the physical, psychological, social and emotional health of the patient.

• The safety of the clients

The service plan must focus on the health as well as the safety of the client. It must include the client’s initial treatment, the subsequent treatment and a discharge plan. Therefore, the development of the service plan provides assurance that clients will receive standard treatment services (Bianco & Amanda, 1996).

The comprehensive assessment of the patients

The assessment must entail analysis and evaluation of disorders resulting from substance use (Minnesota Health Care Administration, 1995).

1. History taking
2. the type of substance that the client abuse
3. the quantity of a substance that the client abuse
4. the reasons behind the drug abuse
5. The patient history should also include medical, social, surgical operations as well as the family history of mental disorders.

Observation

This must include the inspection of the general outlook of the patient, the facial expression, the walking gait, the body structure and the dressing.

Physical examination

The health care professional must examine the patient physically by taking his weight, height, blood pressure, temperature and calculating the body mass index.

The assessment procedure

The treatment facility must use the current assessment procedure:

1. According to this procedure, the health care professional must collect information from the client that is not more than thirty days (Minnesota Health Care Administration, 1995).
2. Additionally, the relatives of the patient as well as the significant others must provide information about the client
3. The relatives of the client can make changes to the existing information. The changes can be through the following modes:

• a phone call
• face-to-face communication
• letter writing

The treatment plan of the patients

The general plan about the treatment of a client at the chemical dependency clinic

The client and the significant others must take part in the formulation of this plan (Bianco & Amanda, 1996). The staff members together with the patient and the significant others must develop this plan after the initial assessment and evaluation of the patient.

The update of the treatment plan

This plan requires a continuous update as the patient’s condition improves or exacerbates. For example, after the evaluation of the patient, the treatment plan must change to fit the identified needs.

The content of the treatment plan

The treatment plan must entail the entire proposed treatment regimen for the patient (Clarke, 2000). Therefore, the chemical dependency clinic must document the patient identified problem during the assessment. Secondly, the member of the staff must develop a treatment plan that contains:

1. the treatment method
2. the resources that will facilitate treatment
3. the goal of the client

The goal must be specific, measurable and achievable.

The presentation of the treatment plan

The treatment plan must be in such a way that the client understands it. For example, it must be clear and precise with no technical terms.

The evaluation of the patient

The health care professionals must ensure that formative evaluation of the patient takes place and the plan is adjusted according to the patient progress (McVinney, 2006). The formative evaluation must include:

1. assessment of the psychological state of the patient
2. assessment of the physical state of the patient
3. evaluation of other people involved in the patient’s care
4. the effect of the treatment on the patient
5. the review of the treatment plan.

The health care professionals must ensure that formative evaluation of the patient takes place on a weekly basis.

The discharge of the patient

The members of the staff must discharge the patient after his or her condition has improved. Thus, the members of the staff must explain to the patient about his condition and the reasons for the termination of the treatment services (Minesota West Publishing Company, 2003).

The documentation

The health care professionals must document a summary of the patient’s condition as well as the discharge plan. Moreover, the health care professionals must explain to the patient the below requirement after discharge from the chemical dependency clinic:

1. what the patient must do while at home
2. when to return for a medical checkup
3. the steps the patients must take in case the condition worsens

The treatment services

According to Minnesota Health Care Administration (1995), this policy must deal with the comprehensive and holistic treatment services that the health care professionals must offer medication therapy.

They include the psychotic medications counseling.

The counseling services must focus on assisting the patient to change his behavior and adapt behavior that does not pose a risk to his health education.

Education must empower the individual with knowledge about the harmful effect of substances abuse.

Rehabilitation

Rehabilitation must entail helping the client to stop abusing the substance.

Other services

1. relationship counseling
2. therapeutic relationship counseling
3. stress management
4. teaching about living skills
5. teaching the patients socialization skills the role of the counselor in the provision of treatment services
6. the location of the treatment facility

The location of the chemical dependency clinic must be in the area outlined in the document that the holder of the license gave to the commissioner. This is because the patients are familiar with this location since it is in the service charter. Additionally, this facilitates the evaluation of the facility by the commissioner to determine if the patients receive quality services.

The medical services

The description of service

Clarke (2000) states that the health care professionals must describe the services related to health that they are offered. The services should include:

1. the nursing services
2. the dietary services
3. the physician services

The procedures for the provision of these services

The health care professional must explain to the patients all the steps that they must follow from admission to discharge.

The consultation services

Consultation services must be available and the patients must know who to consult in case of any problem (Minnesota Health Care Administration, 1995). Therefore, the consultant must be ready to offer psychological services to the patients.

The qualification of the staff

The health care professionals must describe the members of the staff who will be responsible for dispensing and prescribing medication to the patients (McVinney, 2006). For instance:

1. a nurse must administer medication to the inpatient patients
2. a pharmacist must dispense medication to the outpatient patients

The rights of the patients

1. a right of knowing the type of medication
2. A right of knowing the reason for the medication
3. A right of knowing the dosage of the medication
4. A right of knowing the adverse effect

The control of medication

The drugs must be under control so that patients do not get a chance of abusing them. As a result, they must be in a lockable cupboard and the key kept in a safe place (Minesota West Publishing Company, 2003)

The staffing requirement

The qualifications

According to this policy, the chemical dependency clinic must have people who direct treatment and a counselor who has experience in the field of alcohol as well as drugs (Minesota West Publishing Company, 2003).

The allocation of duties

The staff must allocate duties according to the staff qualifications. For instance, the allocation of a treatment director must concern treatment while the duty allocation of the counselor must concern counseling of the patients who abuse drugs

The duties

These health care professionals must be aware that their duties are to provide comprehensive treatment services to the patients.

Additional qualifications

1. Knowledge about basic life support
2. Red cross-training

The procedures at the chemical dependency clinic

Assessment of treatment policies

The chemical dependency clinic must make sure that clients are aware of what is required of them (Bianco & Amanda, 1996). For instance, all clients need screening for mental health problems, HIV as well as tuberculosis. The resulting information must be private and confidential thus shared by the clients and the health care professionals only.

The resources that enhance the provision of treatment

The resources must include materials like gloves, medication, syringes, needles, money and workforce. The chemical dependency clinic must ensure that the resources are always sufficient at all times.

Methods

The chemical dependency clinic must outline the method of provision of treatment that includes the route, the amount, the time and the dosage.

Services

The chemical dependency clinic must state if it is offering inpatient services, outpatient services or both services.

The treatment plan

In case one turns out to have a specific disease, his or her treatment plan must commence and the appropriate services given to him or her. Additionally, the chemical dependency clinic must document the policies regarding treatment. If for whatever reason a client refuses treatment, the reasons behind the refusal require documentation.

The rights of the client

The right to appeal

Clients have the right to petition if the health care professional refuses to screen them (Clarke, 2000). Therefore, the treatment facility must give clients the chance to appeal if the health care professional did not assess and screen them yet they availed themselves of the services. Otherwise, the clients can sue the treatment facility.

The appeal procedures

Treatment facilities should allow the clients to appeal. Additionally, the choice concerning the appeal should not be from the person who made the preliminary verdict about the appeal.

The restriction of extra services

The chemical dependency clinic must have an outline of the situations in which they do not offer treatment services and the reasons behind those situations.

The health care professionals

The policy requirement

1. The chemical dependency clinic must have documented policies that all the staff can access (Minnesota Health Care Administration, 1995).
2. The policies must contain information about staff retention
3. the promotion of staff
4. the description of the job
5. the behavior of the staff
6. the organization structure
7. the staff orientation

The treatment facility must orient its new staff to both the physical and the organizational structure. This orientation is relevant because the staff familiarity with the physical and organizational structure will lead to the provision of secure and suitable treatment services to the clients.

The evaluation of the health care professionals

The psychological states of the staff need investigations because it can have an impact on the service provided to the client. For instance, the possibility of a client receiving the wrong treatment increases when the staff suffers from depression, schizophrenia or traumatic stress disorder (Bianco & Amanda, 1996).

Staff development

All the staff must be trained (Bianco & Amanda, 1996). The training can be on job or outside the job and it should entail:

1. the client ethics
2. emergencies procedures
3. the policies of the treatment facility
4. HIV
5. alcohol and substance
6. the treatment

These training are imperative because they equip health care professionals with knowledge and skills that enhance the delivery of high-quality services. The treatment facilities should develop a culture of on job training where the health care professionals receive training as they work. The importance of on job training is that it saves time while increasing the efficiency and effectiveness of the treatment services.

The personnel files

The holder of the license must keep and maintain a file for each staff member (Clarke, 2000). The file must contain:

1. the staff application form
2. the name of the staff that is responsible for the provision of psychotherapy
3. the documents that show that the staff is oriented to the physical and organization structure
4. the document that shows the staff is ready to work for the treatment facility Therefore, the treatment facility must ensure that the staffs have all these documents before commencing to work. Moreover, the documents must have current information because the information is important in the relationship between the staff and the license holder as well as other staff. For instance, this information will facilitate the treatment of staff with mental disabilities. Furthermore, the treatment facility must keep these files away from the reach of other staff because they contain confidential information about the staff. The confidential keeping of files motivates the staff to provide treatment services because they are at peace since no one can access their private information.

The service initiation and the termination

The service initiation

The chemical dependency clinic must have a policy describing the treatment service before the clients receive the services (McVinney, 2006). Therefore, staff members must know the services that they intend to offer before making a decision of offering those services to the clients. As a result, the health care professionals must determine:

1. the target population
2. the needs of the target population
3. the implementation of services that satisfy those needs
4. the appropriate health care personnel who are going to give effective and efficient treatment services to the clients
5. Documentation

The health care professional must write down a charter showing all the services available at the treatment facility.

Distribution of the charter

The staff members must distribute this service charter prior to the setup of the facility. This is because the accessibility of the offered services to the clients will determine the utility of the treatment facility.

The people not served via the license holder

The health care professional is responsible and accountable during the termination of service of the client or restricting the treatment services to the client because of the client’s health, behavior or criminal activity (Minnesota West Publishing Company, 2003). In this situation, the health care professional must provide services to a client whose sickness is likely to cause self-harm. For instance, a mentally disturbed client who is at risk of self-harm must receive the appropriate intervention or be referred to another facility for the required management. Additionally, if a member of staff has a criminal offense, he or she must receive the appropriate treatment then the case is forwarded to the law agencies because they have proper jurisdictions. Besides, the law agencies can handle the case well because that is their field of practice.

The termination as well as the transfer of the policies

The chemical dependency clinic must have a documented policy that spells out the reasons behind the discharge of the client (Minnesota Health Care Administration, 1995). The documentation must entail:

1. the client behavior
2. the Minnesota statutes procedures
3. the treatment facility procedures concerning the termination.

Therefore, the treatment facility must possess a full analysis of the client’s behavior that led to the termination of service. For instance, a member of the staff can discharge a client with aggressive behavior because this behavior is dangerous to other clients as well as the staff. Therefore, the treatment facility staff must communicate with the client and have him or she understand the reasons for the termination of services. After the termination of services, the client must receive the treatment plan and the relevant advice.

The policies and the procedures that protect the client rights

The rights of the clients

1. the right to receive the proper medication
2. the right to information
3. the right to know the people involved in their care. the right to participate in the treatment activities

The chemical dependency clinic must give patients a statement of their rights as well as their responsibilities. This is important because when clients know their expectations, they will collaborate with the staff as they receive the treatment services. Therefore, during the initiation of treatment, the health care professionals must take the responsibility of explaining to the clients their rights. According to Clarke (2000), when clients know their rights, the possibility of declining treatment decreases because they feel that the staff value them hence they adhere to whatever instructions that they receive.

The grievance procedure

Accessibility

The grievance procedure must be in places where the clients can access and in case they are not accessible and the clients request them, the health care professionals must distribute them.

Discharged patients

Discharged clients must be in a position of receiving the grievance procedure upon request.

The development process

The member of staff must help the clients develop the grievance procedure.

Availability of the relevant contacts

The procedure must have the telephone contacts of the relevant authorities. The relevant authorities include:

1. the human resource department
2. the mental health department
3. the Minnesota department
4. the department of the development disabilities

These contacts are important because the clients will always use them to get in touch with the relevant authority whenever problems occur.

The response to the grievances

In a chemical dependency clinic, the health care professional must respond to the client’s grievances in approximately three days.

Further actions

The clients must take their grievances to the authorities in the highest places if the members of the staff cannot solve their problems.

The photographs of the clients

Any photograph of the client that is relevant for his care is a client record thus filed in the client file. In case any photo taken is for the staff supervision, it must circulate within the treatment facility only. If such a photo, finds its way outside the treatment facility then the health care professionals must investigate and the responsible person receives some punishment.

The policy before a photograph session

Before a photo-taking action, the member of staff must explain to the client:

1. the need for the photo
2. the purpose of the photo
3. The client has a right to accept or refuse and the member of staff needs to respect that right and he or she should not force the client or rebuke him in case the response is negative.

The behavioral emergency procedures

The requirement

The treatment facility must have a document that the staff should adhere to when handling a client who has aggressive behavior that can harm him or other people (Bianco & Amanda, 1996).

The content of the document

1. a plan that can prevent the client from self-harm
2. the telephone number of the emergency personnel
3. the procedure that the staff member should follow in such a circumstance
4. the event upon which initiation of such procedures can take place.

This document is imperative because it allows the member of staff to act in a rational way in case such an event occurs. Besides, it places the member of staff in a defense position in case someone sues him or her.

Application of the procedure

According to Clarke (2000), these procedures are not for the convenience of the health care professional. Furthermore, they are not part of the treatment regimen and their application must be in the event where the safety of the staff and the client is under a compromise.

The coverage

In a treatment facility, the health care professionals must know that this procedure does not cover emergencies like fires as well as storms. Therefore, health care professionals must be cautious when applying this procedure so that they do not go against the law

Infection control

The in-charge of the clinic is completely responsible for instituting an infection control system in the clinic and must follow the guidelines of the ministry of health.

The controlling system

Any infectious disease detected in the clinic must be notified to the concerned authority within the expected period. Any health care professional who has an infectious disease must not report to work until he or she recovers. Additionally, any equipment that becomes contaminated during the treatment of a patient with an infectious disease must be sterilized.

Infection control practice

The clinic must have a record that shows the monitoring and control of waste disposal.

The infection control practices include:

1. Hand washing
2. Use of protective materials like gloves, gowns, masks and boots
3. Disinfection and sterilization of equipment
4. Proper disposal of sharps and infectious wastes
5. Proper management of soiled as well as contaminated linens

Emergency care services

Disaster preparedness

The clinic must provide procedures for responding to injuries that are life-threatening to the patients. Moreover, all the staff must receive training on how to respond to life-threatening emergencies like fire.

1. The clinic must have a written document on disaster preparedness.
2. The health care personnel must understand the plan.
3. The plan must be available for evaluation and recommendation.
4. All the health care workers must assist in a mass casualty event within the vicinity.

The call information in time of an emergency

The call information must be in a conspicuous part of the chemical dependency clinic.

The call information must entail the following:

1. The telephone number of the fire as well as the police departments
2. The telephone number of the staff who must be contacted in time of an emergency.
3. The telephone numbers of the hospitals within the vicinity.

The basic services

The chemical dependency clinic must have a defined system in providing emergency services. The services must include the procedures for saving a life.

During an emergency, the assessment of the patients must be done to determine the kind of services that they require.

Before transferring a patient, the nearby health facility must be informed through a telephone call. Furthermore, the patient must receive life-saving procedures as he or The monitoring and evaluation of the chemical dependency clinic:

The participation

The participation in the drug and the alcohol continuous evaluation

The health care professionals must involve themselves in the evaluation via submission of the information about all clients to the commissioner. The submitted information is for the evaluation of the care that the clients receive. This evaluation is imperative because it motivates the health care professionals to provide quality services to the patients (McVinney, 2006). This is because treatment facilities that provide the best services to their clients in comparison to other treatment facilities receive tokens of appreciation. On the other hand, the patients also benefit from this evaluation because they receive standard care

The request of the commissioner

The health care professionals must give the commissioner any information necessary for the funding procedures. Therefore, the treatment facility must always keep records of all the activities that they undertake. Proper documentation is important because it eases the work of the funding body of tracking the activities of the treatment facility (Minnesota West Publishing Company, 2003). Therefore; it is easier for a facility to receive funds if it has proper records. Finally, when a treatment facility receives funds, it means that the patients will receive quality services. On the other hand, the members of the staff will work hard because their remunerations will increase.

Conclusion

In conclusion, the chemical dependency clinic policies and procedures are very important for the running of the clinic. This is because they assist the staff members to provide quality services that focus on the needs of the patients. On the other hand, the patients receive quality treatment services.

References

Bianco, D., & Amanda, M. (1996). Professional and Occupational Licencing Directory: A Descriptive Guide to State and Federal Licensing, Registration and Certification Requirements. Michgan: Gale Research.

Clarke, R. (2000). Managed Behavioural Health Care Handbook. New York: Jones Barlet Learning.

McVinney, D. (2006). Chemical Dependency Treatment: Innovative Group Approaches. New York: Taylor and Fransis.

Minesota West Publishing Company. (2003). Minnesota Statues Annotated. Minnesota: West Publishing Company.

Minnesota Health Care Administration. (1995). Managed Care Plan for Medical Assistance, General Assistance Medical Care and Minnesota Care: A report by the Minnesota Legislature. Minnesota: Diane Publishing Company.