<< Back

CHH policies posted on PolicyTech

September 10, 2025

The following policies have been published in PolicyTech:

June 2025
Complaints of Inappropriate Colleague Behaviors Involving a Patient_HHC
Continuity of Operations Plan (COOP)_HHC
Hospital Support Person_HHC   
Universal Time Out and Site Verification for Invasive Procedures_HHC
Product Recall Notification_HHC
Guideline for Home Medication Review for ED Patients_CHH
2025 bloodbank annual competency_CHH_LAB
Anatomic Pathology Quality Improvement Plan_LAB_CHH
CHH AP Specimen Drop Off Log
Cross Contamination_CHH_LAB
DPH Clinical Test Requisition
Phlebotomy Scripting Patient Experience_CHH_LAB
Phlebotomy Vein Selection
POC Urine hCG _CHH_LAB
Specimen Identification Form_CHH_LAB
Sunquest Collect – CHH ED Nursing and Respiratory
Sunquest Collect Phlebotomy CHH ED_ CHH_LAB
Sunquest: Fax_CHH_LAB
Components for Preparation of Sterile Compounds_HHC
Hand Hygiene and Garbing_HHC
2025 Hematology Competency Quiz
Anatomic Pathology Reporting of Significant or Unexpected Findings
Clostridioides difficile Prophylaxis in High-Risk Patients Receiving Antimicrobial Therapy_HHC
Cobas PRO Total Protein Urine and CSF_CHH_LAB
Infant Car Seat Challenge_HHC
2025 Heme Cell Identification Competency
Charlotte Hungerford Hospital Severance Policy_HR
Continuous Albuterol Therapy Administration_CHH_Respiratory 
Elevator Failure or Elevator Entrapment of Passengers_CHH_EOC
Emergency Department Acute Behavioral Health Unit (ABU)_CHH
HHC Specimens Unable to Track Form_CHH_LAB
Massive Transfusion Protocol (MTP)  and Emergent Uncrossmatched Blood Transfusion_CHH
Patient Care Observer Guidelines
Processing Specimen For the Gem 5000 Blood Gas Analyzer_CHH_Respiratory
Verifying Turnaround Time for STAT and Routine Tests_CHH_Respiratory
Nuclear Medicine: Receipt and Opening Packages of Radioactive Materials_HHC
Cancellation, No Show, and Late Arrival Policy for Outpatient Wound Care Centers_HHC
Care Assistance Partner (CAP) Program_HHC
Central Venous Catheter (CVC) Provider Insertion_HHC
Cobas PRO Procalcitonin_CHH_LAB
Continuation of Inhaled Prostacyclins from Home_HHC
Desensitization for Chemotherapy and Biologics_HHC
After Hours Medical Oncology Practice Coverage_HHC
Autopsy, Authorization_CHH
Emergency Department Visitation_HHC
Post Mortem Examination Consent
Reporting Impermissible Access, Use, or Disclosure of Protected Health Information
Gifts Policy_HHC
Joint Venture_HHC
IQCP for BD Commercially Prepared “CLSI-Exempt” Media _CHH-_LAB
Aseptic Compounding Technique Overview_HHC
Cleaning, Calibration and Maintenance of Equipment Used for Compounding_HHC
Creatinine Clearance Estimation for Medication Dosing_HHC
Labeling Procedures for Compounded Sterile Products_HHC
Sterile Master Formulation and Compounding Record_HHC
Storage, Handling, Packaging, Shipping and Transport of Compounded Sterile Products_HHC
BAL Fluid Examination_CHH_LAB
Evidence of Compliance for CAP Computer Facility Checklist Requirements_HHC_LAB
Heme and Coag checklist May 2023
Laboratory General Checklist 2023
Venous Thromboembolism (VTE) Prophylaxis in Trauma Patients_HHC
De-identification and Limited Data Sets Policy
Inactivated Influenza Vaccine_HHC
Management of Investigational Drugs (IDS)_HHC
Notification to Medicare Inpatient Beneficiaries Regarding Discharge Appeal Rights_HHC
Venous Thromboembolism (VTE) Prophylaxis in the Hospitalized Obstetric Patient_HHC
Infrared Thermography Skin Scanning_HHC
Male External Urine Management System_HHC
July 2025
Drug Supply Chain Security_HHC
Leaves of Absence_HHC
Military Service Leave_HHC
Malnutrition and the Hospitalized Patient_HHC 
Nurse Residency Program_HHC
Nutrition Order Entry_HHC   
Outpatient Wound Care Consenting Process_HHC
Palliative Care Scope of Practice_HHC
Targeted Temperature Management After Cardiac Arrest_HHC
Plain Language Emergency Communications across Hartford HealthCare_HHC.
Biosafety Cabinet Maintenance log_CHH_LAB
Blood Bank Daily Maintenance_CHH_Lab
Blood Bank Daily Reagent quality control
Credo Cooler Panel Log_CHH_LAB
Health and Safety Hazard Communication for Contractors_HHC
Laboratory Safety Standardization Team Charter_HHC_LAB
Clozapine Monitoring_HHC  
Creating GHS Labels using the Velocity EHS Chemical Management Platform_HHC_LAB
Laboratory Chemical Hygiene Plan_HHC Lab
Managing Laboratory SDS using Velocity EHS eBinder_HHC_LAB
Virtual Patient Observation_HHC
Pharmacist Automatic Intravenous to Oral Conversion_HHC
Scissor and Boom Lift Use_HHC
Venous Thromboembolism (VTE) Prophylaxis for Orthopedic and Spine Surgery Patients_HHC
Wound Center Skin Injury Treatment Management_HHC
Cord Blood Testing_CHH_LAB
Annotation of Images by Technologist_HHC 
Bone Marrow Biopsy and Aspiration_HHC 
Medical Record Documentation Requirements_HHC
Administration of Gadolinium_HHC
Alcohol Withdrawal Management_HHC
Calcium Channel Blocker (CCB) and/or Beta Adrenergic Blockers (BB) Overdose Induced Hypotension Treatment with High Dose Insulin_HHC
Chemical Pleurodesis and Blood Patch_HHC
Contrast Administration Orders for_CHH_RAD
CT Exam Protocols_CHH_RAD
CT Protocol/Dose Summary Page_CHH_RAD
CT, Transfers from Other Facilities_CHH_RAD
Diagnoses, Highest Priority_CHH_RAD
IV Medication Administration Reference Grid_HHC
Look Alike and Sound Alike Medications_HHC
Neonatal Medication Preparation_HHC
Rasburicase (Elitek®) : Management of  Hyperuricemia Associated with Tumor Lysis Syndrome (TLS)_HHC
Risk Evaluation and Mitigation Strategy (REMS) Patient Safety Program_HHC 
Treatment of Complex Parapneumonic Effusions/Early Empyema – tPA (alteplase- ACTIVASE)  + DNase (dornase alfa -PULMOZYME) instillation via pigtail or chest tube_HHC
Abnormal Diagnostic Test Results_CHH_Adult Ambulatory Behavioral Health
Admission Screening Adult Ambulatory Behavioral Health_CHH_Behavioral Health Center
AFTER HOURS CRISIS CALLS_CHH_Adult Ambulatory Behavioral Health                   
Amission to Adult Ambulatory Behavioral Health Services_CHH_PHP/BHC/IOP
CANCELLATION/MISSED Appointment P0licy_CHH_Behavioral Health Center
CLINICAL SUPERVISION_CHH_ All Adult Abulatory Behavioral Health
Competency Assessment Program_CHH_RAD
Discharge from Treatment_CHH_BHC,PHP,IOP
Exam Flow, Emergency Department_CHH_RAD
Exam Flow, Outpatient_CHH_RAD
Exam, Priority Inpatient & Emergency Department Orders_CHH_RAD
Fall Prevention and Management  Guidelines for Adult  Ambulatory Behavioral Health _CHH_BHC PHP IOP
film Badges, Non-Staff_CHH_RAD
Film Badges_CHH_RAD
Fire Prevention and Safety- Ambulatory Behavioral Health_CHH_PHP IOP BHC
Fire Procedure- Memorial Hall_CHH_BHC IOP PHP
INDIVIDUALIZED TREATMENT PLAN_CHH_BHC PHP IOP
Integrated Behavioral Health Services_CHH_BHC PHP IOP
MULTIDISCIPLINARY TEAM/UTILIZATION  REVIEW_CHH_all adult Ambulatory Behavioral Health                      
Nebulized Tranexamic Acid for Hemoptysis and Alveolar Hemorrhage_HHC
Newborn Congenital Heart Disease Screening_HHC
No Show/No Call_CHH_PHP IOP
Non Patient De-escalation_CHH_Adult Ambulatory Behavioral Health
Patient Charting_CHH_Adult Ambulatory Behavioral Health
Patient Elopement_CHH_PHP IOP
Patient Supervision_CHH_PHP IOP
Physical Examinations_CHH_Adult Behavioral Health Ambulatory Services
Umbilical Vessel Catheterization and Peripherally Inserted Central Catheter (PICC) in the Newborn_HHC
Fire, SPD Response_CHH_SPD
Infection Control in SPD_CHH_SPD
In-Service Education_CHH_SPD
Custom LIS_HHC_LAB
Interfaces_HHC_LAB
LIS Training_HH_LAB
Alcohol-Based Hand Rub_HHC
Emergency Preparedness and Operations Plan_HHC
Instruments and Implants, Process for Receiving/Returning_CHH_SPD
Lot Control_CHH_SPD
Mechanical Monitoring of Sterilization_CHH_SPD
Monitoring biological_CHH_SPD
Monitoring External Controls_CHH_SPD
Off-Site Transportation of Contaminated Instruments_CHH_SPD
Orientation and Training_CHH_SPD
Packing of SPD Processed Supplies_CHH_SPD
PERT Alert Bags_CHH_SPD
Pharmacy Substitution of Biosimilar Products_HHC 
Protection of Sterile Supplies from Contamination_CHH_SPD
Recall of Supplies Following Manufacturer’s Wanings_CHH_SPD
Recall, SPD Processed_CHH_SPD
Release of ET0 Sterilized Supplies_CHH_SPD
Reuse of Disposables_CHH_SPD
Rotation of Supplies_CHH_SPD
Routine and Project Cleaning of SPD Department_CHH_SPD
Routine Maintenance of Decontamination & Sterilization Equipment_CHH_SPD
Safety Guidelines for SPD_CHH_SPD
Shelf Life and Expiration Dating of SPD Processed Items_CHH_SPD
Steam Sterilizer_CHH_SPD
Sterilization, Instruments, Outside Facilities_CHH_SPD
Steris Washer, Routine Cleaning_CHH_SPD
Adult Transthoracic Echocardiography_CHH_ECHO
Cleaning and Disinfecting Equipment_CHH_ECHO
Competency Assessment Technical Staff_CHH_CARD DIAG
Critical Value Reporting for Holter, Event and MCT Monitoring_CHH_CARD DIAG
Definity Echo Contrast, Administration of_CHH_ECHO
Definity Echocardiogram Ordering Protocol_CHH_ECHO
Ebola/Emerging Pathogen Preparedness: Acute Care/Inpatient Settings_HHC
Equipment Maintenance Program _CHH_ECHO
Event and MCT Monitoring_CHH_CARD DIAG
Holiday Coverage_CHH_CARD DIAG
Patient Identification_CHH_CARD DIAG
Pharmacologic (non-exercise) Stress Test with Nuclear Imaging_CHH_CARD DIAG
Physician and APP Coverage for Cardiac Stress Testing_CHH_CARD DIAG
Physician Variability/Discrepancy_CHH_ECHO
Quality Improvement_CHH_ECHO
Saline Contrast Transthoracic Echocardiography_CHH_ECHO
STAT EKG Interpretation Policy_CHH_CARD DIAG
Transesophageal Echocardiogram_CHH_ECHO
Blanket Warming_CHH
Controlled Drug Kits for Hartford Healthcare Emergency Medical Services, Northwest Region_CHH
Outpatient Clinical Operations Manual_HHC_Rehabilitation Network
Public Safety Policy for Emergency Management_CHH_Security
Pyxis Automated Dispensing Cabinet Policy _CHH     
Report of Death_CHH
Vacancy Times of Airborne Precautions Rooms Between Patients_CHH
Antibiotic Desensitization_HHC
Infection Prevention Precautions, Ambulatory Care Settings_HHC
Multi-Drug Resistant Organism Management_HHC
Ornamental Plants and Flowers_HHC
Blood Bank Weekly Maintenance_CHH_LAB
Cobas PRO Total Bilirubin_CHH_LAB
Cryostat Decontamination_CHH_LAB
Quality of Formalin
Xpert: MRSA PCR_CHH_LAB
Nondiscrimination and Reasonable Modifications for Section 1557_HHC
Powered Air Purifying Respirator Program (PAPR)_HHC 
Pronation Therapy for the Mechanically Ventilated Patient_HHC
Skin Injury Prevention and Treatment_HHC  
Universal Respiratory Etiquette_HHC
Required Daily Maintenance for the Echo Lumena_CHH_LAB
Sample Indices_CHH_LAB
Above Ceiling Work_HHC
Hot Work Program_HHC
Nursing Stroke/TIA Swallow Screen (**STROKE/TIA patients ONLY**)_CHH
Slip, Trip, and Fall Prevention_HHC
Laboratory Emergency / Disaster Plan_CHH_LAB
Radiology Adverse Reaction Boxes_HHC 
Sperm Retrieval from Deceased Patient_HHC
Vancomycin – Pharmacy to Dose_HHC 
Virtual Health (Telehealth)_HHC
August 2025
Laboratory Evacuation Plan_CHH_LAB
Use and Disclosure of Protected Health Information Without an Authorization_HHC
Wernicke’s Post Bariatric Surgery_HHC
ICU Esophagogastric Tamponade Tube_HHC
Medical Emergency-Rapid Response_CHH
Normal Ranges and Critical Values_CHH_LAB
Patient Linking_CHH_LAB
Preparing Slides with Albumin _CHH_LAB
Determination of Brain Death / Death by Neurologic Criteria (BD/DNC) in Adults_HHC
Reporting Significant Findings_CHH_LAB
Transfusion Reaction Investigation_CHH_LAB
Urinalysis_CHH_LAB
CT, Equipment Downtime Back-Up coverage_CHH_RAD
Equipment, Inspection of_CHH_RAD
Equipment, Personnel Operation_CHH_RAD
Inpatient ACCESS to the Outside_CHH             
Pre-MRI Safety Screening_CHH_RAD
PTO Holiday Coverage_CHH_RAD
2025 Phlebotomy Competency Quiz
BB Monthly Cover for QC Summary_CHH_LAB
Clinical Assessment and Documentation in the Outpatient Oncology Infusion Setting_HHC
Contrast, Oral Contrast Dispensing for X-ray_CHH_RAD
Corrective Action Plan_CHH_RAD
CT Dose Alert_CHH_RAD
Film Badges, Radiation Accident_CHH_RAD
Images, Previous Studies for Interpretation_CHH_RAD
Infection Control, Barium Enemas_CHH_RAD
Interpretation Discrepancies, Emergency Department for Teleradiology (CT, Ultrasound, Nuclear Medicine)_CHH_RAD
Nuclear Medicine, Minor spills Emergency Procedures_CHH_RAD
Patient from Residential Facility, Supervision of_CHH_RAD
Radiation Protection C-Arm_CHH_RAD
Reagent Revision Review Form_CHH_LAB
Reporting of Values Outside of Linearity Values_CHH
Shutdown of Gem Premier 4000 & 5000 Analyzer_CHH
TEE Transducer Leakage Current Testing_CHH_ECHO
Visitors in the Operating Room_CHH_OR
Directory of Infectious Diseases Reference Grid_HHC
Interim Life Safety Measures_HHC
Leaving Against Medical Advice_CHH
Tuition Assistance_HHC
Ultra CWII Cell Washer Functional Calibration_CHH_LAB
Care of the Patient who has Experienced Sexual Assault_HHC
Business Associate Policy
Chronic Obstructive Pulmonary Disease (COPD) Care Pathway_HHC
Confiscation of Contraband Controlled Substances_CHH 
Designated Record Set_HHC
Employment of Relatives and Personal Relationships_CHH 
Formulary Reference List_HHC
Joint Notice of Privacy Practices
Medication Refrigeration: Monitoring Policy_CHH_Pharmacy
Surgical Site Skin Preparation_HHC
Universal Influenza Prevention_HHC
Diabetes Management in Pregnancy_CHH__OB/GYN
Medical and Legal Requests for Laboratory Specimens_CHH_LAB
Bioterrorism Readiness and Response Plan_HHC
Hazardous Medication Reference List_HHC
Informed Consent for Surgery, Anesthesia, Blood Transfusions and Other Procedures_HHC
Laboratory Exposure Monitoring Program_HHC_LAB
DCA Contact Guide_HHC
Location of Emergency Equipment Code Carts_CHH_Emergency Department
Suspicious Person(s)_CHH_Security
Admission of Patients to the Maternity Unit_CHH_OB/GYN
Amniocentesis at the Bedside_CHH_OB/GYN
Antitrust Compliance_HHC
ASA Classifications_CHH_ANES.
Breach Investigation and Notification Requirements for Protected Health Information Policy
Breastfeeding and Lactation of Normal Newborn and Well Mother_CHH_OB/GYN
Cesarean Delivery_CHH_OB/GYN
Emergency Intubation Medication Kit_CHH
Epidural Anesthesia-Management of the Pregnant Patient_CHH_OB/GYN
Holter Monitoring_CHH_CARD DIAG
Imminent Delivery_CHH_OB/GYN
Information Blocking Compliance_HHC
Labor Support Equipment and Supplies_CHH_OBGYN
Laboratory: Review of Delayed Results/Call Back Process_CHH_ED
Medical Equipment Safety Assessment-Inpatient Psychiatry_CHH
Observers in Labor/Delivery_CHH_OB/GYN
Patient Right to Request Amendment to Protected Health Information (PHI)
Properties of Antiretroviral Medications Reference Grid_HHC 
Quality Plan Blood Gas Lab_CHH
Radiation Safety: Holding Patients During Radiology Exams_HHC
Radiation Safety: Signs for Appropriate Use_HHC
Support Persons in Labor & Delivery_CHH_OB/GYN
Transfer of Perinatal and Neonatal Patients to Tertiary Care_CHH_OB/GYN
BB Computer Downtime Product Modification Form_CHH_LAB
Infection Control Risk Assessment for Construction and Renovations_HHC
Blood Bank Administrative Data Entry_CHH_LAB
Laboratory Planned Time Off Policy_CHH_LAB
Xpert-Cepheid: Strep-A Assay_CHH_LAB
CHH Chemistry and Toxicology Checklist 122024
Laboratory Proficiency Testing_HHC_Lab
Nursing Professional Development Orientation_CHH