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This is facility-dependent and should be made in collaboration with key stakeholders involved in infection prevention and control and emergency management. Your institution will need to refer to its internal processes and policies to decide whether your institution may deploy Emergency Management procedures. 

Documentation of processes and procedures for HCID awareness could include Electronic Medical Records (EMR), paper records, laboratory, emergency management processes, and notification processes (e.g., who do you notify? How? Who do your staff know to notify?). Follow your local and state regulations. 

Consideration for the differences in policies, protocols, guidelines, standard work, and other documentation types. Do not deviate from policies (e.g., restraints and blood transfusions). Documentation of clarifying points of entry, intent of screening, and who is included can be documented in your Infection Control Annual Plan, the annual Infection Control Risk Assessment (ICRA), and meeting minutes from IPC committee. 

Category: Policy & Procedures and the Joint Comission Standards

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