Outpatient Procedures Master

OUTPATIENT PROCEDURES
TABLE OF CONTENTS
100 CASE MANAGEMENT

101 COUNSELING/THERAPY
101.1 OUTPATIENT DHS/TANF SUBSTANCE ABUSE PROGRAM/GROUP
101.2 OUTPATIENT CO-OCCURRING PROGRAM/GROUP
101.3 COMANCHE/COTTON DRUG COURT PROGRAM
101.4 OUTPATIENT AFTERCARE SUBSTANCE ABUSE PROGRAM/GROUP
102 OUTPATIENT MEDICATION CLINIC
103 PSYCHOLOGICAL TESTING
105 ORAL MEDICATION REFILLS
107 LABORATORY PROCEDURE
107.1 LAB CORP CONTRACT
108 PHYSICAL EXAMS FOR OUTPATIENT
110 MEDICATION ERRORS
111 MEDICAL EMERGENCIES
112 OBSERVING AND REPORTING CONVULSIVE SEIZURES
113 EVALUATION OFCONSUMERS IN JAIL
114 PROTECTION OF CONSUMERS' RIGHTS DURING VISITATION
115 CRISIS INTERVENTION
116 CODE FOR AGITATED CONSUMERS
117 CLIENT/FAMILY COMPLAINT/GRIEVANCE PROCESS
200 ADMISSION CRITERIA

201 APPOINTMENT PROCEDURES
300 DOCUMENTATION POLICY

301 DISCLOSURE OF CONFIDENTIAL INFORMATION
302 REFERRALS TO PSYCHOSOCIAL REHABILITATION
303 REFERRALS TO VOCATIONAL SERVICES
304 CONTACTS
306 MEDICATIONS REVIEW AND MEDICAL HISTORY/PAIN ASSESSMENT
307 PHYSICIANS' ORDERS
308 CONSULTATIONS
310 SUICIDE LETHALITY CHECKLIST
311 HOMICIDE LETHALITY CHECKLIST
312 COMPREHENSIVE TREATMENT PLANNING
313 PROGRESS NOTES
400 DISCHARGE PLANNING

401 DISCHARGE OF INACTIVE CONSUMERS
500 JTCMHC ACTING AS REPRESENTATIVE PAYEE FOR THE SOCIAL SECURITY

INCOME OF CONSUMERS
501 FLEX FUNDS
600 LEAVE WHEN SERVICES ARE TEMPORARILY REDUCED DUE TO HAZARDOUS

WEATHER FOR SATELLITES
601 BOMB THREAT PROCEDURE FOR SATELLITES
602 FIRE PLAN FOR SATELLITES
603 SEVERE STORM WARNING/TORNADO WARNING PROCEDURES FOR SATELLITES
OUTPATIENT PROCEDURES
TABLE OF CONTENTS
700 TRAVEL EXPENSES

701 WORKSHOP ATTENDANCE
800 GUIDLEINES FOR UNIVERSAL PRECAUTIONS

801 INFECTION CONTROL-HAND WASHING
802 INFECTION CONTROL-EMPLOYEE RISK EXPOSURE
803 INFECTION CONTROL-CLEANING AND DISINFECTION OF CONSUMER CARE EQUIPMENT
OUTPATIENT PROCEDURE
PROCEDURE #: 100
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RGANIZATIONAL UNIT: OUTPATIENT SUBSTANCE ABUSE SERVICES PAGE__1__OF__1__
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SUBJECT: OUTPATIENT CASE MANAGEMENT EFFECTIVE DATE: 31 JUL 04
DATE REVIEWED: 01 FEB 08
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PURPOSE
To ensure that case management is being conducted in the most professional manner possible
while adhering to the guidelines regulated by DMHSAS and accrediting agencies.
PROCEDURE
WHO WHAT
Case Manager 1. Reviews the record and contacts the consumer, who is
diagnosed with a severe mental illness and/or a
Co-occurring disorder, to set an appointment upon
assignment. The emphasis is on maintaining or improving
the current level of functioning, unless a deteriorating
physical or mental condition exists. Screens and assesses
for possible case management needs.
2. Empowers the consumer in obtaining and making use of any

available resources if the individual lacks any of the basic
needs, such as food, clothing, and shelter. When
appropriate, refers and links to community resources.
Contacts family, friends, community programs, and other
agencies.
3. Encourages and/or assists the consumer to find activities or

hobbies, participate in social or community groups, etc., to
enrich life, once basic needs are met.
4. Advocates for the consumer in networking with other agencies,

identifying unmet needs, and trying to devise or foster new
services.
5. Ensures that services are being provided in a community

setting, the residence of the consumer, or any other
appropriate setting(s) based on the individual needs of the
consumer.
6. Maintains contact with each consumer as needed with a

minimum of once per month, regardless of level of care.
PROCEDURE #: 101
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SUBJECT: COUNSELING/THERAPY EFFECTIVE DATE: 04 APR 93
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PURPOSE
To ensure that counseling/therapy is being conducted in the most professional manner possible
while adhering to the guidelines regulated by DMHSAS and accrediting agencies.
PROCEDURE
WHO WHAT
Licensed Clinician 1. Reviews the record and contacts the consumer, who Is
diagnosed with a severe mental illness, substance abuse,
emotional disturbance, depression, and/or a
Co-occurring disorder, to set an appointment upon
assignment.
2. Encourages the consumer to discuss problems, needs, and

goals.
3. Compiles an initial treatment plan with the consumer, based

on his/her problems, needs, and goals by the fourth session,
unless otherwise dictated by a third party reimbursement
source.
4. Selects the appropriate best practice modality that provides the

best intervention for the presenting problem(s).
5. Provides counseling services as needed based on

consumer preference(s).
6. Guides consumer in finding appropriate solutions for his/her

problem(s), discusses progress toward current objectives,
and readiness for discharge as objectives are met.
7. Provides HIV/AIDS education, counseling, and referral for

testing for drug dependent consumers.
PROCEDURE #: 101.1
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SUBJECT: OUTPATIENT DHS/TANF EFFECTIVE DATE: 01 JAN 05
SUBSTANCE ABUSE GROUP DATE REVIEWED: 01 FEB 08
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PURPOSE
As required by ODMHSAS Contract with Department of Human Services (DHS) toward services for all
potential referrals for assessment and/or treatment for substance abuse and/or co-occurring issues.
PROCEDURE
WHO WHAT
Substance Abuse Clinician 1. Clinician will receive referral form from DHS Caseworker for
administration of a SASSI (Substance Abuse Subtle
Screening Inventory) questionnaire to identify a need for
substance abuse/ co-occurring treatment. Each potential
consumer must be seen within 10 days of referral.
2. Upon successful completion of the SASSI, the clinician will

score and determine a need for further assessment as to a
ranking of “Low Probability” versus “High Probability”. If the
potential consumer scores a Low Probability the clinician will
submit a report to DHS Caseworker within 5 working days
stating the consumer is not in need of services at this time.
If the potential consumer scores a High Probability the
clinician will administer the ASI (Addiction Severity Index),
ASAM-PPC-2R, and drug urine screen at that time to
determine a referral into the group/individual process. The
clinician will then submit a report stating the consumer is in
need of treatment and will be referred into the
group/individual process within 10 working days.
3. Upon receiving referral from DHS Caseworker for the

group/individual process, each consumer will be scheduled
for an intake within 3-5 days. The group requirements are
Monday, Wednesday, and Thursday 9 a.m. – 12 p.m. for a
period of 8 weeks. The individual requirement is 1-3 times
per week for a period of 8 weeks. Each participant is
required to attend at least 3 AA/NA meetings per week while
in the program and is subject to random drug urine screens
throughout.
PROCEDURE #: 101.1
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SUBJECT: OUTPATIENT DHS/TANF EFFECTIVE DATE: 01 JAN 05
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WHO WHAT
4. Clinician will complete intake paperwork on each consumer to

include the following: psychosocial assessment, alcohol and
drug history, brief pain inventory, consent of release of
confidential information, authorization for outpatient treatment,
HIPPA notice of privacy practices and acknowledgment
signature form, consumer rights, responsibility and appeal
form, program rules of conduct, consumer grievance
procedure, authorization of treatment advocate and must have
licensed clinician perform and sign diagnostic evaluation for
each consumer. Clinician will also screen and assess
consumer for possible case management and mental health
needs.
5. Upon successful completion of the 8 week group process,

the consumer will have the option of being referred to an
Aftercare program. The Aftercare group meets 1x per week
for 1 ½ hours for a period of 12 weeks. The client will be
required to attend 3 AA/NA meetings per week and be
subject to random drug urine screens while in the program.
Substance Abuse Supervisor 6. Supervisor will assure that there will be a 55:1 ratio of
clinician versus consumer maintained through staff
assignment upon entry into program. Supervisor will assure
that there will be a 12:1 ratio of clinician versus consumer for
group services.
PROCEDURE #: 101.2
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SUBJECT: OUTPATIENT CO-OCCURRING EFFECTIVE DATE: 01 JAN 05
PROGRAM/GROUPS DATE REVIEWED: 01 FEB 08
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PURPOSE
Establish a set procedure for clinicians to adhere to for referral process into Co-Occurring services.
PROCEDURE
WHO WHAT
Intake Clinician 1. Clinician will complete intake paperwork on each consumer to

licensed clinician and/or physician perform and sign diagnostic
evaluation for each consumer.
Substance Abuse Supervisor 2. Supervisor will receive referral from one of three sources, the
Triage Unit, Inpatient Unit or Case Management Unit.
Supervisor will then confirm a need for Co-Occurring services
and assign consumer to a Co-Occurring Clinician at that time.
Substance Abuse Clinician 3. Clinician will contact the consumer upon receiving referral from
supervisor to establish an appointment. Each clinician will
contact assigned consumer within 2 days of referral. Each
consumer will be offered Co-Occurring services which include
group/ individual sessions, case management, family support,
vocational rehab support, and medication clinic.
4. Upon first session with each consumer, clinician will administer

the ASI (Addiction Severity Index) and the ASAM PPC-2R to
establish appropriate level of care.
5. Clinician will monitor, provide case management, support and

document services for each consumer based on his/her
preferences or needs. Clinician will be required to perform
random drug urine screens for each consumer.
PROCEDURE #: 101.2
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SUBJECT: OUTPATIENT CO-OCCURRING EFFECTIVE DATE: 01 JAN 05
PROGRAM/GROUPS DATE REVIEWED: 01 FEB 08
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WHO WHAT
6. Upon referral for the group process, the clinician will educate
each consumer toward mental health and substance abuse
issues. Each consumer will be required to attend group
Monday, Wednesday and Thursday 9 a.m. to 12 p.m. for a
period of 8 weeks. Each participant will be required to
attend at least 3 AA/NA meetings per week, and be subject
to random drug urine screens while in the program. Upon
successful completion of this 8 week process the consumer
will have the option of attending an Aftercare group 1x per
week for 12 weeks. The Aftercare group meets 1x per week
for 1 ½ hours for a period of 12 weeks. The client will be
required to attend 3 AA/NA meetings per week and be
subject to random drug urine screens while in the program.
Substance Abuse Supervisor 7. Supervisor will ensure that there will be a 55:1 ratio of clinician
versus consumer maintained through staff assignment upon
entry into program. Supervisor will ensure that there will a 12:1
ratio of clinician versus consumer fro group services.
PROCEDURE #: 101.3
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SUBJECT: COMANCHE/COTTON COUNTY EFFECTIVE DATE: 01 JAN 05
DRUG COURT PROGRAM DATE REVIEWED: 01 FEB 08
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PURPOSE
As required by ODMHSAS Drug Court requirements, all clinicians will adhere to referral process and
group procedures.
PROCEDURE
WHO WHAT
Drug Court Coordinator 1. Coordinator will submit assessment referral to Drug Court
Clinician and set an appointment time.
Drug Court Clinician 2. Clinician will accept referrals for Drug Court Program only from
Drug Court Coordinator.
Drug Court Clinician 3. Clinician will perform an initial assessment to consist of the
ASAM PPC-2R, URICA (University of Rhode Island Change
Assessment), ASI (Addiction Severity Index) and drug urine
screen. Upon completion of these tools, the clinician will
determine a need for substance abuse treatment within the
drug court program. If the client is a good candidate, there will
be a referral for the program given to the Comanche/Cotton
County Drug Court Board.
Drug Court Board 4. Upon receiving the assessment results and referral from
clinician, the board will then vote to accept or deny consumer
into this process. If the board accepts the consumer into the
process, there will be an intake appointment set at that time for
consumer to begin group, individual and monitoring sessions.
Intake Clinician 5. Clinician will complete intake paperwork on each consumer to

licensed clinician perform and sign diagnostic evaluation for
each consumer. At this time clinician will screen and assess
for co-occurring disorders.
PROCEDURE #: 101.3
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SUBJECT: COMANCHE/COTTON COUNTY EFFECTIVE DATE: 01 JAN 05
DRUG COURT PROGRAM DATE REVIEWED: 01 FEB 08
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WHO WHAT
Drug Court Clinician 6. Clinician will educate, monitor and document progress of each
consumer throughout this 5 Phase, 2 year process. Consumer
will initially be required to attend group 1-2x per week for 12
months, 2-4x per month for 6 months and then 1x per month 6
months. Throughout this process the consumer will be
required to attend at least 3 AA/NA meetings per week and be
subject to random drug urine screens. The consumer will also
be required to attend individual sessions initially 2x per month
for 12 months and 1x per month for 12 months.
Drug Court Clinician 7. Clinician will be responsible for monitoring and reporting back
to Drug Court Board every 2 weeks as to the progress and
participation of each consumer. If the consumer has been non-
compliant, the clinician must report immediately to the Drug
Court Coordinator for immediate sanctions process. The
sanctions process will be carried out by assigned Drug Court
Judge.
Substance Abuse Supervisor 8. Supervisor will assure that there will be a 55:1 ratio of
clinician versus client maintained through staff assignment
upon entry into program. Supervisor will assure that there
will be a 12:1 ratio of clinician versus consumer for group
services.
PROCEDURE #: 101.4
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SUBJECT: OUTPATIENT AFTERCARE EFFECTIVE DATE: 01 JAN 05
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PURPOSE
Establish procedures for referral and monitoring of Aftercare groups and processes.
PROCEDURE
WHO WHAT
Substance Abuse Clinician 1. Clinician will receive referral from 2 sources, an Outpatient
Substance Abuse Clinician or Triage clinician, and confirm
successful completion of residential or outpatient substance
abuse program.
Substance Abuse Clinician 2. Clinician will educate, monitor and document each consumer’s
progress toward relapse prevention. Each consumer will be
required to attend Aftercare group/individual sessions 1x per
week for 12 weeks, attend at least 3 AA/NA meetings per
week, and will be subject to random drug urine screens while in
the program. Clinician will continue to monitor co-occurring
and case management needs.
Substance Abuse Supervisor 3. Supervisor will assure that there will be a 12:1 ratio of clinician
versus consumer maintained through staff assignment upon
entry into Aftercare groups only.
PROCEDURE #: 102
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RGANIZATIONAL UNIT: OUTPATIENT SERVICES PAGE__1__OF__2__
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SUBJECT: OUTPATIENT MEDICATION CLINIC EFFECTIVE DATE: 31 JUL 04
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PURPOSE
To provide efficient and professional operation of medication clinics for those individuals seeking
medication evaluation, medication adjustment, and/or medication maintenance..
PROCEDURE
WHO WHAT
Referring Clinician 1. Obtains a medication appointment for consumer from

Outpatient receptionist.
2. Appointment slip is provided to consumer with date and time

of appointment.
Nurse 3. Secures charts from medical records for all consumers

scheduled to be seen for the day.
4. Upon each visit, records blood pressure, pulse, and weight of

consumer and performs AIMS testing when indicated.
5. Maintains and updates medications as needed.
6. Assesses for side effects, allergies, and contraindications of

medication(s).
Physician 7. Interviews consumer, assesses symptoms, and prescribes

medication(s) consistent with state and federal law.
8. Assesses need for co-occurring services, such as group or

individual sessions.
Nurse 9. Obtains consumer’s signature on the “Consent for

Treatment” form for specific medications.
10. Notes orders and completes paperwork for any laboratory

work that has been ordered.
Consumer 11. Obtains a medication clinic appointment slip for next doctor
visit from Outpatient Receptionist.
PROCEDURE #: 102
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SUBJECT: OUTPATIENT MEDICATION CLINIC EFFECTIVE DATE: 31 JUL 04
WHO WHAT
12. Meets with Medication Assistance Program staff to assess

for possible assistance.
Medication Assistance 13. Assesses consumer as to whether criteria is met for

Program Clinician assistance.
14. Turns prescription(s) into pharmacy to receive medication(s).
Nurse 15. Returns all charts to Medical Records by 4:45 p.m.

PROCEDURE #: 103
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SUBJECT: PSYCHOLOGICAL TESTING EFFECTIVE DATE: 31 JUL 04
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PURPOSE
To provide guidelines for requesting Psychological Testing.
PROCEDURE
WHO WHAT
Clinician 1. Psychological evaluation request is obtained outlining specific

reasoning for testing.
2. Routes request to Psychological services.
Psychologist 3. Contacts consumer for next available appointment.

PROCEDURE #: 105
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SUBJECT: ORAL MEDICATION REFILLS EFFECTIVE DATE: 31 JUL 04
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PURPOSE
To provide written guidelines for medication refills.
PROCEDURE
WHO WHAT
Doctor, Nurse, or Determination is made to give medication at decided intervals. This

Pharmacist will guard against a possible overdose with a consumer who has
abused medications in the past or who has been diagnosed with a
Co-Occurring disorder. This information is relayed to the Outpatient
Receptionist.
Outpatient Receptionist 1. Medication refills are noted on prescription in the lower left hand.
2. Dates for return refills are placed on the appointment slip and
explained to the consumer.
Consumer 3. Prescription is then taken to the pharmacy to be filled.

PROCEDURE #: 107
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SUBJECT: LABORATORY PROCEDURE EFFECTIVE DATE: 31 JUL 04
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PURPOSE
To provide written guidelines in conjunction with staff physician/psychiatrist and with contract laboratory to
ensure proper procedure is being followed.
PROCEDURE
WHO WHAT
Nurse 1. Request the procedure on the laboratory request form.
2. Lithium levels require the consumer to have blood drawn in

the morning before taking any of the medication.
3. If the procedure requires fasting the consumer should

instructed as to the requirements.
4. If there is doubt that fasting is necessary, inquire with the

laboratory.
A. HMO’s (Medicaid and Commercial)
Physician 1. Writes laboratory procedures on prescription pad ( to include

physician’s signature) to be taken by consumer to his or her
PCP (Primary Care Physician) to have laboratory procedures
done according to his or her PCP’s request.
Nurse 2. Notes physician’s order(s) in consumer’s chart.
3. Instructs consumer as to requirements of laboratory

procedure(s) if fasting is required.
4. Instructs consumer as to time frame requirements if

laboratory procedure is a drug level.
B. MEDICARE
Physician 1. Writes laboratory procedures on “Doctor’s Order” sheet.
2. Writes requested laboratory procedures ( to include

physician’s signature) and DSM-IV diagnosis on prescription
pad to be taken by consumer to lab of choice.
PROCEDURE #: 107
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WHO WHAT
Nurse 3. Notes physician’s orders.


6. Upon receiving laboratory results, he or she directs them to

the prescribing physician for review. In the event of
abnormal levels he or she follows up with the consumer
either directly or through the assigned case manager for
referral to his or her medical doctor and files results in
consumer’s record.
C. MEDICAID (fee for service)/ CHARITY CARE
Physician 1. Writes laboratory procedures on “Doctor’s Order” sheet.
Nurse 2. Notes physician’s orders.


5. Upon receiving laboratory results, he or she directs them to

the prescribing physician for review. In the event of
abnormal levels he or she follows up with the consumer
either directly or through the assigned case manager for
referral to his or her medical doctor and files results in
OUTPATIENT
PROCEDURE
PROCEDURE #: 107
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WHO WHAT
Nurse 6. Records requested laboratory procedures on designated

requisition (completing all information according to contract
requirements). Requisition is then taken by consumer to
designated area at this Center for lab work.
PROCEDURE #: 107.1
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SUBJECT: LAB CORP CONTRACT EFFECTIVE DATE: 31 JUL 04
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PURPOSE
To provide written guidelines for laboratory corp procedures.
PROCEDURE
WHO WHAT
Nurse 1. Completes laboratory requisition with highlighted areas filled in.

(See attached example.)
2. In the physician’s name box put JTC-Outpatient, Duncan,

Altus, Anandarko, TANF, SAFE, or AIDg. This aids in the
return of the results to the correct area.
3. Sends a Xerox copy to Finance Department for monitoring

payment for services rendered.
4. Saves last carbon copy and files in a folder for own reference.
5. Places extra specimen sticker number from requisition form

and places on record collection on green lab sheet.
Medical Records Staff 6. Receives printed copy of reports and sends to area requesting
documents.
PROCEDURE #: 108
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SUBJECT: PHYSICAL EXAMINATION FOR EFFECTIVE DATE: 31 JUL 04
OUTPATIENT DATE REVIEWED: 01 FEB 08
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PURPOSE
To create awareness regarding physical examinations.
Laboratory examinations are not routinely performed on our Outpatient consumers.
PROCEDURE
WHO WHAT
Physician Determines the need for a physical examination by employing
the following steps:
1. Determines when the consumer was last treated by a physician

and when a completed physical examination was performed.
2. Determines whether the consumer is aware of the presence of

any medical problems.
3. Determines what, if any, medication the consumer is taking.
4. Determines whether there is a indication for medial follow-up or

medical diagnostic work-up.
5. Reviews medications and medical history form contained in

the Psychosocial Assessment. Makes final determination
concerning the necessity for a physical exam and refers
consumer to local MD/DO.
Physician/Nurse 6. Assists the consumer in making arrangements for a physical

examination with his or her private medical physician.
7. Inform primary clinician of need for medical follow-up.

PROCEDURE #: 110
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SUBJECT: MEDICATION ERRORS EFFECTIVE DATE: 31 JUL 04
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PURPOSE
To provide written guidelines for reporting medication error(s).
Any medication error or incident shall be reported to the Unit Physician immediately on discovery.
PROCEDURE
WHO WHAT
Responsible Staff 1. Reports error to the Outpatient director and Outpatient

Physician. In the event the staff responsible for the error is
not available any staff discovering the error shall report the
error to the Outpatient Director and Outpatient Physician.
Outpatient Nurse 2. Notifies the physician during working hours.
Physician 3. Writes order(s), as indicated, for care of consumer and

documents the occurrence in the progress notes.
Nursing Staff 4. Carries out physician’s order(s).
Responsible Staff 5. Completes the medication incident report form. In the event the
staff responsible for the error is not available any staff
discovering the error shall complete the medication incident
report form. It shall be signed by the person who is responsible
for the error as soon as possible and documented in the
consumer’s clinical record.
Director of Nursing Services 6. Reviews all medication errors/incidents. Identifies any patterns
of medication error/incident. Recommends corrective action to
Incident Review Committee.
Incident Review Committee 7. Reviews recommendations for corrective action. Forwards

recommendation to Quality Assurance Committee.
Performance Improvement 8. Reviews recommendations from Incident Review

Committee Committee. Tracks medication errors over time looking for
trends and ways to improve the process.
CORE 9. Reviews recommendations from Performance Improvement

Committee. Makes final disposition/recommendation.
PROCEDURE #: 111
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SUBJECT: MEDICAL EMERGENCIES EFFECTIVE DATE: 31 JUL 04
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PURPOSE
To provide written guidelines for handling medical emergencies.
PROCEDURE
WHO WHAT
Staff 1. Calls switchboard to have available physician paged

immediately.
Switchboard 2. Pages all available physicians to area where incident

occurred.
Physician 3. Examines individual to determine present condition and

action to be taken.
Nurse 4. Nurse assists physician in examination for individual.
Designated 5. Calls ambulance, if determined necessary.
Physician or CPR Certified Staff 6. Administers necessary life-saving techniques.
Staff 7. Complete CIR (Critical Incident Report) and routes to Director

of Program Evaluations for review and signature.
8. Documents incident in consumer’s progress note.
Director of Program Evaluations 9. Routes CIR to Risk Manager for review and sends to Executive
Director for review.
10. Follows up with staff to review the incident and debrief staff as
needed.
11. Discusses CIR in the Safety Committee and PI Committee.

PROCEDURE #: 112
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SUBJECT: OBSERVING AND REPORTING EFFECTIVE DATE: 31 JUL 04
CONVULSIVE SEIZURES DATE REVIEWED: 01 FEB 08
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PURPOSE
To provide written guidelines for observing and reporting convulsive seizures.
PROCEDURE
WHO WHAT
Nurse/Mental Health Aide 1. Checks for breathing; if consumer is not breathing, tilts head
back to open airway.
2. Keeps airway clear, positions consumer on abdomen or

side, if possible, to prevent inhalation of food or saliva to
lungs.
3. Stays with consumer.
4. Permits consumer to lie where fallen; observes for possibility

of injury from fall and loosens tight clothing.
5. Provides first aid, if necessary, in case of injury.
6. Protects head from injury during convulsive movements.
7. Provides quiet, undisturbed environment for rest while

regaining consciousness.
8. Checks blood pressure and pulse rate after seizure, every 5

minutes for first 15 minutes.
Registered Nurse 9. Notifies physician, reports, and follows doctor’s orders, and
notes.
10. Records seizure in the following manner:
a. Date, time, duration of seizure, vital signs, and recovery

period.
b. Activity of patient just prior to seizure aura- headache,
dizziness, nausea, outcry prior to seizure.
PROCEDURE #: 111
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PROCEDURE
WHO WHAT
c. Parts of body involved in seizure, including eye

movements.
d. Salivation or incontinence of urine or feces.
e. Color and condition of skin; dusky, warm, moist, dry, cool,
clammy, etc.
f. Describe direct observations in basic English, rather than
offering opinions, conclusions, or interpretations; chart the
description in the order in which seizure events occurred.
g. Describe activity after the seizure, i.e, sleep, quiet, irritable.
NOTE: DO NOT attempt to force objects, i.e, pencils, tongue

depressors, into patient’s mouth during seizure.
PROCEDURE #: 113
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SUBJECT: PRESCRIBING AND DISPENSING EFFECTIVE DATE: 31 JUL 04
OF MEDICATIONS TO INMATES OF THE COUNTY/CITY JAIL DATE REVIEWED: 01 FEB 08
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PURPOSE
To provide written guidelines for prescribing and dispensing of medications to inmates of
the county or city jail.
PROCEDURE
WHO WHAT
City/County Jail Nurse 1. Notifies JTCMHC staff of need for evaluation for medication or
treatment.
JTCMHC Staff/Doctor 2. If inmate is currently receiving medication from Center, doctor

assesses medication currently prescribed for continuation or
discontinuance.
Registered Nurse/Social Worker 3. Takes medications to the jail.
Physician 4. Reviews progress and conducts examinations of any inmate

receiving medication from JTCMHC every four weeks from
date of request. Conducts said review and examination on
monthly basis throughout inmate’s incarceration and
documents such in the inmate’s medical record.
PROCEDURE #: 114
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SUBJECT: PROTECTION OF CONSUMER’S RIGHTS EFFECTIVE DATE: 31 JUL 04
DURING VISITATION DATE REVIEWED: 01 FEB 08
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PURPOSE
To ensure protection of consumer rights.
PROCEDURE
WHO WHAT
Director of Outpatient Services 1. Arranges for group visitations for educational or professional
purposes only. Schedules these visits so they are the least
disruptive.
2. Advises consumers in the waiting areas, prior to group

visitation, to prepare consumers for the visit.
3. Reminds staff of consumer’s rights to confidentiality, advises

staff not to call consumer by name.
PROCEDURE #: 115
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SUBJECT: CRISIS INTERVENTION EFFECTIVE DATE: 31 JUL 04
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PURPOSE
To provide the most efficient and appropriate treatment for a consumer in crisis.
PROCEDURE
WHO WHAT
Consumer and/or Significant 1. Calls the Center or comes to the Center requesting help with
the problem.
Switchboard or Outpatient 2. Makes an attempt to see what the immediate problem(s) is/are
Receptionist and directs the consumer to hi or her case manager or
outpatient counselor. If primary clinician is unavailable,
contacts the crisis case manager or Triage staff to see the
client.
Crisis Case Manager or 3. Interviews the consumer to determine immediate need(s) of the
Triage Staff consumer and initiates appropriate treatment.
4. Follows up and provides further assistance to the consumer,

if needed.
PROCEDURE #: 116
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SUBJECT: CODE FOR AGITATED CONSUMERS EFFECTIVE DATE: 31 JUL 04
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PURPOSE
To provide written guidelines for the safety of consumers, staff, and visitors.
The code word for seeking help with agitated consumers or medical emergencies will be
“Mr. Magoo” plus the location of the emergency, which can be called from any location.
PROCEDURE
WHO WHAT
Staff 1. Will announce on the overhead, by dialing 70, “Mr. Magoo”

plus the location of the emergency.
Designated Staff 2. Responds to emergency and enters area quietly to assess

(Trained in CAPE) need for consumer management. Initiates verbal intervention
and, if necessary, holds or physically restrains consumer.
3. Escorts consumer to Quiet Room area in IP Unit, if necessary.
Designated Auxiliary Staff 4. Provides assistance for staff called to respond. Removes
(Trained in Basic CAPE) debris in area if damage has occurred. Clears area of
consumers, if necessary, and explains necessity for action
taken. Ensures availability of help.
Physician/Registered Nurse 5. Provide medical assistance in cases of medical emergencies.

PROCEDURE #: 117
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PURPOSE
The Jim Taliaferro Community Mental Health Center shall have a process for resolving consumer/family
grievances and complaints and shall adhere to the ODMHSAS guidelines governing the protection of
consumer rights. Consumer/family grievances and complaints shall be reported to the Supervisor and
resolved at the lowest level possible.
PROCEDURE
WHO WHAT
JTCMHC Consumer Advocate 1. Assures the name and telephone number of the ODMHSAS
Consumer Advocate, assigned by the Advocate General’s
Office, as well as the JTCMHC Consumer Advocate’s name
and number, shall be posted in all treatment areas.
Consumer/Family 2. Completes, in writing, the Consumer Grievance form JT3-37.
Staff 3. Receives complaints or grievances form a consumer and/or

family member and shall inform hi or her supervisor of the
complaint. The complainant shall be informed that all
populations served have access to the Consumer Advocate,
the ODMHSAS Consumer Advocate Attorney, as well as the
JTCMHC Consumer Advocate. All grievances received
should be responded to within 3 working days.
a. When appropriate, all efforts shall be made by staff and

JTCMHC Consumer Advocate to resolve the
complaint/grievance informally. The Executive Director
shall be informed of complaints/grievances. The Director
may elect to participate in the resolution process as
appropriate.
b. If the JTCMHC Consumer Advocate or the ODMHSAS
Consumer Advocate cannot resolve the
complaint/grievance informally within 5 calendar days,
the Inpatient Grievance Procedure, as outlined by
Oklahoma Administrative Code, shall be initiated.
PROCEDURE #: 117
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PROCEDURE
WHO WHAT
Unresolved Outpatient complaints/grievances may use

the Inpatient procedure as a guideline if necessary.
4. All consumer deaths and allegations of consumer

abuse/neglect of any kind shall immediately be referred to the
ODMHSAS Consumer Advocate and the JTCMHC Consumer
Advocate.
5. Incident Reports shall be filed by JTCMHC staff according to

policy/procedure and reviewed in Incident committee.
ODMHSAS Consumer 6. Interviews the consumer/family concerning unresolved

Advocate complaints/grievances. The ODMHSAS Consumer Advocate’s
activities/recommendations are then determined by guidelines
and policies set forth by the ODMHSAS Advocacy Division.
Staff 7. JTCMHC and leadership shall cooperate fully with

investigations conducted by the ODMHSAS Consumer
Advocate and/or representatives from the Advocate General’s
Office. Staff and leadership shall cooperate fully with the
ODMHSAS Consumer Advocate and/or representatives from
the Advocate General’s Office in the resolution of complaints.
Consumer Advocate 8. Kelly McCuiston

PROCEDURE #: 200
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SUBJECT: ADMISSION CRITERIA EFFECTIVE DATE: 31 JUL 04
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PURPOSE
To provide a written reference of the criteria required for admission into Outpatient Services.
PROCEDURE
WHO WHAT
Outpatient Admission Staff 1. Any individuals or families may be seen by outpatient for any
mental, emotional, substance abuse, or Co-Occurring
problems that meets DSM IV Diagnostic criteria with a resulting
Axis I or II diagnosis.
2. Consumers are voluntary, unless ordered by the court.
3. We do not refuse services to individuals based on age, race,

sex, religion, or income.
4. Seriously mentally ill or Co-Occurring consumers may be seen

by case managers for any problems or needs.
PROCEDURE #: 201
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SUBJECT: APPOINTMENT PROCEDURES EFFECTIVE DATE: 31 JUL 04
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PURPOSE
To ensure that appointments made in Outpatient Services are done efficiently and consistently.
PROCEDURE
WHO WHAT
A. Outpatient counselors and case managers make their own appointments.
Switchboard 1. Receives the walk-in consumer or telephone call from the

consumer who wants to make an appointment with his or her
case manager/counselor.
2. Directs the call or walk-in directly to the clinician. If the

clinician is unavailable, directs call or walk-in to the
Outpatient receptionist.
Outpatient Receptionist 3. Attempts to locate the clinician, if he or she is not with

another consumer. If clinician is not available, takes
consumer’s name and phone number for the clinician to call
consumer to make an appointment.
Counselor or Case Manager 4. Calls consumer to make an appointment.
B. Appointments with the physician are made through the Outpatient Receptionist.
Switchboard 1. Receives the walk-in consumer or telephone call from the

consumer who wants to make an appointment with his or her
physician.
2. Directs the call or walk-in directly to the Outpatient

receptionist to obtain an appointment.
Outpatient Receptionist 3. Determines when consumer’s last appointment was and

confers with the outpatient nurse to determine necessity of
an appointment. If appears to be an emergency, refers to
Triage.
4. Gives consumer appointment slip with next appointment

date, time, and physician and writes appointment down in
schedule book.
PROCEDURE #: 300
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SUBJECT: DOCUMENTATION PROCEDURES EFFECTIVE DATE: 02 AUG 04
REFERENCES: ODMHSAS Standards and Criteria #401.11
JCAHO Consolidated Standards PE.2.3, TP.1.3.2.1.4
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PURPOSE
To provide written guidelines to ensure documentation follows the criteria of ODMHSAS and JCAHO
standards.
PROCEDURE
It is the policy of JTCMHC that all outpatient medical records will contain the following information:
1. Consumer’s name and chart number.
2. Signatures by staff completing the forms. The signature should consist of their full name or
first initial and last name along with their highest degree and licensure, if applicable. All forms
and entries should be dates with the time, month, day, and year of completion.
WHO WHAT
A. Outpatient counselors and case managers make their own appointments.
Intake Staff 1. Completes admission paperwork including computerized

admission form for all new consumers at the time of
contact/admission or readmission to the system.
2. Admission paperwork includes: confidentiality statement,

consumer rights, consent for follow-up, consent for treatment,
psychosocial assessment, brief pain inventory, grievance
procedure, designation of treatment advocate, progress note,
any required release of information forms, and any addendum
which might be required by specialty departments.
Physician/ Primary Clinician 3. Completes treatment planning according to Treatment Plan

policies.
4. Completes the Physician’ s Orders and writes prescriptions for

medication(s) when indicated. All orders must be signed and
dated with the time, month, day, and year by the physician.
5. Completes Mental Status Exam and Diagnostic Evaluation

when required.
Outpatient Nurse 6. Completes the Medication Record (Flow Sheet) on clients

receiving medication. It will document what medication(s) were
prescribed and the date It was given. It also documents vital
signs and weight of consumer on date medication(s) were
prescribed.
PROCEDURE #: 300
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SUBJECT: DOCUMENTATION PROCEDURES EFFECTIVE DATE: 02 AUG 04
REFERENCES: ODMHSAS Standards and Criteria #401.11
JCAHO Consolidated Standards PE.2.3, TP.1.3.2.1.4
****************************************************************************************************************
PURPOSE
WHO WHAT
7. Completes the Allergic (red highlighted) sticker and posts on

front of record hardback chart. All pertinent medical conditions,
allergic reactions, special status situations, i.e. suicidal potential,
harm to others will be included on this sticker. The nurse will
update on a yearly basis with any changes by drawing a single
line through it to delete and add new information as needed by
the documenting staff initials and date beside entries.
Clinician 8. Completes the Progress Notes according to the Progress Note

Policy. Progress notes must be written within 24 hours of date
and time of services. Each visit or transaction, including failure
to show, will be documented.
PROCEDURE #: 301
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SUBJECT: DISCLOSURE OF CONFIDENITAL INFORMATION EFFECTIVE DATE: 02 AUG 04
****************************************************************************************************************
PURPOSE
To ensure that privacy of each consumer is maintained.
PROCEDURE
WHO WHAT
Outpatient Counselor, Nurse 1. Completes the “Consent for Disclosure of Confidential

Case Manager, etc. Information” form, including to whom the information is to be
given, address, purpose of the disclosure, exact information to
be disclosed, and the signature of the consumer (see attached
form).
2. Witnesses the signature of the consumer and signs as witness

on the form.
3. Routes the form to Medical Records.
Medical Records 4. Files the “Consent for Disclosure of Confidential Information”

form in the consumer’s clinical chart.
5. Compiles and sends the necessary information to the

appropriate agency.
PROCEDURE #: 302
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SUBJECT: REFERRALS TO PSYCHOSOCIAL EFFECTIVE DATE: 02 AUG 04
REHABILITATIVE SERVICES DATE REVIEWED: 01 FEB 08
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PURPOSE
To establish guidelines for proper referral to rehabilitative service.
PROCEDURE
WHO WHAT
Referring Clinical Staff 1. Completes referral form and forwards to physician for signature
and approval.
2. Forwards to Psychosocial staff for their review.
3. Arranges for consumer to meet the Psychosocial staff and tour

the facility.
Psychosocial Staff 4. Reviews the clinical chart and interviews the consumer to make
a determination for acceptance into the program.
5. Notifies the referring clinician of determination.
6. Completes appropriate paperwork on all consumers

accepted into the Psychosocial Rehabilitation Program.
7. Arranges with consumer or referring clinical staff when the

consumer should begin program and if the consumer needs
transportation to the program.
PROCEDURE #: 303
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SUBJECT: REFERRAL FOR VOCATIONAL SERVICES EFFECTIVE DATE: 02 AUG 04
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PURPOSE
To establish guidelines for proper referral to vocational service.
PROCEDURE
WHO WHAT
Case Manager 1. Completes Supported Employment Referral form.
Supported Employment Staff 2. Reports to case manager progress on referral.

PROCEDURE #: 304
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SUBJECT: CONTACT FORM EFFECTIVE DATE: 02 AUG 04
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PURPOSE
To establish guidelines for proper referral to vocational service.
PROCEDURE
WHO WHAT
Staff 1. Receives a phone call or a walk-in request for information,

referral, and/or intake appointment.
2. Completes JT-1-105, Contact Data Core, and signs it.
3. Sends completed contact forms to their Supervisor for review.
Supervisor 4. Completes a review to ensure all required fields of the form

are completed.
5. Sends the completed forms to JTCMHC Network

Information Services for input into ICIS/BHIS.
PROCEDURE #: 306
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SUBJECT: MEDICATIONS REVIEW AND MEDICAL EFFECTIVE DATE: 02 AUG 04
HISTORY/PAIN ASSESSMENT DATE REVIEWED: 01 FEB 08
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PURPOSE
It is the policy of Jim Taliaferro Community Mental Health Center that a Medication(s) Review and
Medical History will be completed on all admissions to Community Programs.
PROCEDURE
WHO WHAT
Pharmacist/RN/Clinician 1. Completes Medication(s) Review and Medical History page,

included in Psychosocial Assessment at intake for
consumers being admitted to Community Programs. (Page 3
of the Psychosocial Assessment)
2. Completes the Brief Pain Inventory and places completed form

behind the Psychosocial Assessment in the chart.
a. If the first question of the Brief Pain Inventory is NO, no

further questions will be asked. Staff signs and dates the
bottom of the page.
b. If the first question of the Brief Pain Inventory is YES, the

Brief Pain Inventory will be completed in its entirety. Staff
signs and dates the bottom of the page.
c. Arranges appropriate follow-up with the consumer’s

Primary Care Physician if one is known/identified or makes
a referral for pain management if needed.
d. Provides education concerning pain management to

include, but not limited to, literature on the nature of pain,
safe and effective use of medication(s), and effects/side
effects of medication(s).
PROCEDURE #: 306.1
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SUBJECT: MEDICATIONS ADMINISTRATION DATE REVIEWED: 01 FEB 08
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PURPOSE
It is the policy of Jim Taliaferro Community Mental Health Center that a Medication Administration
procedure will be adhered to on all admissions to Community Programs for those consumers diagnosed
with a mental illness, substance abuse, and/or Co-Occurring disorder.
PROCEDURE
WHO WHAT
Physician 1. Interviews consumer, assesses symptoms, and prescribes

medication(s) consistent with state and federal law.
2. Obtains consumer’s signature on the “Consent for

Treatment” form for specific medications.
Registered Nurse 3. Identifies consumer by verifying name, birth date, and photo
within consumer clinical record.
4. Verify and note Physician’s order.
5. Administers PO medications/injections as prescribed by

Physician consistent with JTCMHC Policy.
6 Maintains and updates medications as needed on medication

log and progress note.
7. Educates consumer regarding side effects, possible drug

interactions, therapeutic effectiveness.
8. Assesses for side effects, allergies, and contraindications of

medication(s). Requires consumer remain at Center for a
minimum of 30 minutes for observation.
PROCEDURE #: 307
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PURPOSE
To provide written guidelines for transcribing and filling prescriptions.
The Jim Taliaferro Community Mental Health Center Pharmacy will give the consumer prescriptions for
non-formulary medications to be filled outside of the Center at their own expense. Should the consumer
fail to keep his or her appointment with the physician, the Registered Nurse consults the physician as to
course of action. If the consumer misses a second physician appointment, no medication will be given
until evaluated by the physician.
PROCEDURE
WHO WHAT
Physician 1. Fills in prescription with date, consumer name, name of

drug, refill number, amount, and frequency.
Consumer 2. Presents to Pharmacist.
Pharmacist 3. Includes the following on filled prescription labels.
A. Prescription ledger filled out at time prescription filled:

1. Date
2. Physician
3. Prescription number
4. Consumer name
5. Week supply
6. Number of pills dispensed
7. Name of drug
4. Dispenses to consumer with pertinent information pertaining to

adverse reaction of warning involved with drug therapy.
5. Refills prescriptions and adds to amount sufficient quantity to

prevent waste of medication(s) until next physician
appointment.
6. Updates consumer drug profile.

PROCEDURE #: 308
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SUBJECT: GENERAL CONSULTATIONS EFFECTIVE DATE: 02 AUG 04
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PURPOSE
To provide written guidelines for obtaining consultations.
Consultation with another psychiatrist may be requested only by the consumer’s attending physician or
psychiatrist. A clinician can request a consultation with a physician or with any other discipline through
appropriate channels.
PROCEDURE
WHO WHAT
Attending Physician, or the 1. Request for consultation must be with reason for request.
Primary Clinician (See attached form)
PROCEDURE #: 310
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SUBJECT: SUICIDE LETHALITY CHECKLIST EFFECTIVE DATE: 02 AUG 04
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PURPOSE
To provide guidelines when a clinician suspects a consumer may be suicidal.
PROCEDURE
WHO WHAT
Clinician/Case Manager 1. Completes front page of “Suicide Lethality Checklist” from

consumer’s statements; assesses severity of risk according
to score and clinical judgment.
2. Takes action described on back of form and documents in

3. Notifies Supervisor.
PROCEDURE #: 311
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SUBJECT: HOMICIDE LETHALITY CHECKLIST EFFECTIVE DATE: 02 AUG 04
****************************************************************************************************************
PURPOSE
To establish guidelines for when a clinician suspects a consumer may be homicidal.

PROCEDURE
WHO WHAT
Clinician/Case Manager 1. Completes front page of “Homicide Lethality Checklist” from

consumer’s statements; assesses severity of risk according
to score and clinical judgment.
2. Takes action described on back of form and documents in

3. Notifies Supervisor.
4. Notifies the threatened person, Director, and law enforcement

officials.
5. Completes Center Incident Report in accordance with

established policy
PROCEDURE #: 312
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PURPOSE
Treatment planning is a mechanism by which professional staff members of the multidisciplinary team
decide, with the consumer, what goals are to be reached and which therapeutic methods are appropriate
to reach said goals.
A comprehensive treatment plan is to be developed at the time of admission when a diagnostic evaluation
is completed. A comprehensive treatment plan is then completed at least once a year thereafter (see
attached OP/Satellite Procedures for this). Treatment plans should always be updated when the
following circumstances exist:
1. Change of service focus. Example: referral from case management to A&D services.
2. When consumer goes from Outpatient to Inpatient or vice versa.
3. Change in treatment plan problems.
4. Significant medication changes. Example: no longer on psychotropic medication or switch to
an injection medication.
PROCEDURE
WHO WHAT
Clinician/Case Manager 1. Assesses consumer’s needs/condition and plans treatment

with consumer. Presents to treatment team.
Treatment Team 2. Discusses and agrees on:
a. Problem(s) to be dealt with

b. Long-term goals
c. Functional strengths and limitations
d. Objectives
e. Interventions, frequency, and staff assigned
f. Criteria for discharge
g. Signature
Case Manager /Consumer 3. Reviews the comprehensive treatment plan with the consumer
and obtains signature of consumer if agreed to.
4. Documents if consumer refuses to sign the comprehensive

treatment plan as well as reason for refusal.
PROCEDURE #: 312
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PROCEDURE
Procedure for Treatment Plan Review
WHO WHAT
Each Team Member 1. Reviews consumer’s contacts for the period and assesses
consumer’s progress in meeting objectives.
Treatment Team 2. Discusses progress.
3. Agrees on new short-term goals/objectives and modalities.
4. Documents new plans on the review form and signs.

PROCEDURE #: 313
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SUBJECT: PROGRESS NOTES EFFECTIVE DATE: 02 AUG 04
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PURPOSE
To ensure that documentation follows guidelines of DMHSAS and accrediting agencies.
Progress notes should be specific statements related to the consumer’s progress on the treatment plan
goals. Assessment information and other consumer related information, as well as treatment provided, is
to be included in the progress notes. All progress notes are to be dated and contain time (beginning and
ending), discipline, and worker’s full name or first initial, last name with their highest degree and licensure,
if applicable.
PROCEDURE
WHO WHAT
Outpatient Staff 1. Records progress notes at each contact (entry should be

completed by next working day).
2. Writes date, time, and short-term goal number in left hand

columns.
Note: “SOAP” format is not required.
3. Signs the note with job title, degree, or licensure.

PROCEDURE #: 400
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SUBJECT: DISCHARGE PLANNING EFFECTIVE DATE: 02 AUG 04
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PURPOSE
Provides a written reference of criteria required to complete a discharge.
The discharge planning process begins with admission and the setting of goals. As goals are met,
discharge or the need for additional goals is discussed.
PROCEDURE
WHO WHAT
Clinician 1. Discusses discharge with consumer as goals are met; decision

to discharge is made jointly with consumer.
2. Completes “Outpatient Discharge Summary” and computerized

discharge forms.
PROCEDURE #: 401
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SUBJECT: DISCHARGE OF INACTIVE OUTPAITENT EFFECTIVE DATE: 02 AUG 04
CONSUMERS DATE REVIEWED: 01 FEB 08
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PURPOSE
ODMHSAS Standards and Criteria VI B.3
It is the policy of Jim Taliaferro Community Mental Health Center that consumers who have not received
any services within 90 days shall be discharged after it is determined that services are no longer needed
or desired.
PROCEDURE
WHO WHAT
Clinician/Case Manger 1. Initiates follow-up with all consumers who have not received
services within 90 days, by telephone, visit, or letter, and
documents in the record. Makes appointments if desired.
2. Discharges consumer within 2 weeks of the contact if the

consumer is no longer in need of services in both his or her
own and the Clinician/Case Manager’s opinion.
3. Discharges the consumer if he or she absolutely refuses

services and documents on contact.
PROCEDURE #: 500
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SUBJECT: JTCMHC ACTING AS REPRESENTAIVE PAYEE EFFECTIVE DATE: 31 JUL 04
FOR THE SOCIAL SECURITY INCOME DATE REVIEWED: 01 FEB 08
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PURPOSE
To act as payee for the Outpatient consumers who have been deemed unsuitable to receive their Social
Security Income directly, and have no friends or family members able or willing to take on the
responsibility. Upon determination, by a Case Manager, that a consumer meets the above policy criteria,
he or she will begin the process of opening a payee account with the Accounting Department and prepare
the appropriate request for the Social Security Administration.
PROCEDURE
Opening a Payee Account with Accounting
WHO WHAT
Case Manager/Consumer Two forms will be needed:
1. A detailed budget prepared by the consumer and a

schedule of cash allowance withdrawals. This budget
should be signed by both the consumer and case
manager and will be revised yearly as changes occur.
2. A signed agreement form stating that the consumer agrees

to have JTCMHC act as his or her payee and the conditions
of that relationship. The conditions being:
a. No interest can be paid on these funds, but should

the consumer be in a position to establish an interest
bearing account in the future, the case manager
would assist them in the process.
b. That all requests for funds are made through the

case manger.
c. That any requests received for funds received, in the

form of a memo, in the Accounting Department by
10:30am will be available to the case manager by
3:30pm that afternoon.
PROCEDURE #: 500
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WHO WHAT
Finance Officer/Acting Agent Receiving SSI Checks

Arrangements to have the consumer’s Social Security Income
received and deposited into the Center’s bank account will be the
responsibility of the case manager. A receipt will be issued and
forwarded to the case manager when a check is received by the
Accounting Department or direct deposited into the bank. This
deposit will follow the requirements of the State accounting
regulations. The deposits will then be entered into the Patient Trust
Accounting Program.
Case Manager/Consumer/ Payment of bills

Finance Officer/Acting Agent The case manager will prepare a memo for the Accounting Department
and affix the bill. The case manager retain a copy of the memo and bill
for his or her records. Upon receipt of the memo, the Accounting
Department will type a check, obtain signatures, copy and mail the
check, and request a receipt. The transaction is then entered into the
Patient Trust Accounting Program. The receipt is filed with the check
for payment upon arrival.
Case Manager/Consumer/ Payment of expenses without a bill

Finance Officer/Acting Agent The case manager will issue a memo describing the expense and to
whom the check will be made out including name, address, telephone
number, and Tax ID/SSN of the business/individual. The case
manager will retain a copy of the memo for his or her records. Upon
receipt of the memo, the Accounting Department will type a check,
obtain signatures, copy the check, and give it to the case manager and
request that he or she obtain a receipt. The transaction is then entered
into the Patient Trust Accounting Program. The receipt is filed with the
check for payment upon arrival.
Case Manager/Consumer/ Request for Cash

Finance Officer/Acting Agent The case manager will prepare a memo for the Accounting Department
specifying the amount. The case manager retain a copy of the memo
for his or her records. The Accounting Department should receive the
memo by 10:30am. The cash will be available for disbursement to the
case manager by 3:30pm that afternoon, unless it is the first or last
business day of the month, when no transactions are accepted. The
transaction is then entered into the Patient Trust Accounting Program.
PROCEDURE #: 500
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WHO WHAT
Case Manager Monthly Ledger

The case manager should maintain a ledger sheet indicating the
monthly deposits and withdrawals. The ledger sheet should have four
columns labeled deposits, checks issued for bills paid, cash
withdrawals, and balance, which should be updated with each
transaction.
Case Manager/Consumer/ Accounting Documentation and Month End Reconciliation

Finance Officer/Acting Agent The Accounting Department will maintain an Individual Client’s
account. Both the consumer’s name and chat number will be used as
identifiers. Each transaction is entered in to the Patient Trust
Accounting Program. Each case manager will be responsible to verify
that his or her ledger sheet balance reconciles with the balance of the
consumer’s account as determined by the Accounting Department.
Spot audits for reconciliation of the balance recorded may be
requested at any time with the case manager and Accounting
Department. This should be done on a monthly basis and whenever
questions arise. Each case manager will fill out a payee slip with each
consumer to verify that the consumer has received the money noted.
Each case manager will then place the payee slip in the consumers
chart and supply a copy of slip to consumer if requested.
Finance Officer/Acting Agent Compliance with Federal and State Guidelines

This Accounting procedure must meet all Federal and State guidelines.
If new guidelines are enacted the procedures should be modified to
respect them.
PROCEDURE #: 501
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SUBJECT: FLEXIBLE FUNDS REQUEST EFFECTIVE DATE: 02 AUG 04
****************************************************************************************************************
PURPOSE
To ensure that JTCMHC consumers have access to funds that may be used for emergency purchases,
usually on time, and goods and services critical to maintain consumers within the community.
ACCEPTABLE EXPENDITURES
1. Emergency food.
2. Consumer transportation to needed services.
3. Temporary/emergency housing.
4. Emergency medication other than psychotropics and/or needed medical supplies.
5. Needed medical services for which there is no other sources of payment.
6. On an emergency basis, first month’s rent, rental deposits and/or monthly rent payments to
prevent out of community placement.
PROCEDURE
WHO WHAT
Case Manager/Therapist 1. Completes JT-530, Flexible Fund Request form, detailing the
justification for the flex fund.
2. Assures that these services are not available through other

resources.
Program Coordinator/ 3. Reviews the Flexible Fund Request and approves or denies.
Director of Program Evaluation
4. If denied, request is sent back to Case Manager for more
documentation/justification.
5. If approved, sends the form to the JTCMHC Accounting

Department for review and action.
PROCEDURE #: 600
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SUBJECT: LEAVE WHEN SERVICES ARE TEMPORARILY EFFECTIVE DATE: 02 AUG 04
REDUCED DUE TO HAZARDOUS WEATHER CONDITIONS DATE REVIEWED: 01 FEB 08
(AUTOMATICALLY ALLOWED AUTHORIZED ABSENCES)
****************************************************************************************************************
PURPOSE
It is the policy of JTCMHC that the Center remain sufficiently staffed so that essential services are
provided at all times and that the potential danger to public property, consumers, and others is reduced to
a minimum in the event of hazardous weather. All Center employees are to at their scheduled work
stations unless the Executive Director/Designee declares non-essential personnel be released or
excused from reporting to work due to hazardous weather conditions. Essential personnel are those
individuals who occupy critical positions that are required to maintain essential services. Announcements
of general reductions of service apply to all departments including Satellite Clinics of JTCMHC.
PROCEDURE
WHO WHAT
Executive Director/Designee 1. Notifies Department heads if a decision to reduce operations is

made during the normal administrative working hours of 8am to
5pm, Monday through Friday.
Essential Personnel 2. Remain at work.
Non-essential Personnel 3. Remain at work if required by necessity of operational

requirements. Non-essential personnel staff who leave early
will be given excused absences and the option to use
accrued enforced leave, compensatory time, or annual
leave.
Executive Director/Designee 4. Makes decision as to whether or not reduce operations outside

of normal administrative operating hours due to notification
made through the “Weather Alert System.”
5. Announcement made be made on local TV and radio, if

possible. Decisions of this type will be made on a day-to-
day basis with a new notice issued each 24 hours.
Essential Personnel 6. Report to work as requested.
Non-essential Personnel 7. Report to work if necessitated by operational requirements.

Non-essential personnel who do not report to work will have the
option to use accrued enforced leave. More than one option
may be exercised to account for automatically authorized
absences. If the absence cannot be accounted for by exercising
the options listed, leave without pay will be utilized.
PROCEDURE #: 600
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WHO WHAT
Supervisors 8. Allow employees to make up time lost due to hazardous weather

if work load option is selected. Center Policy I-C-28, “Overtime
Compensatory Time” will be followed. Employees who are non-
exempt under the Fair Labor Standards Act will be allowed to
make up time lost only if accomplished during the same work
week. This is defined as a work week adjustment and is
necessary to avoid accrual of time and one-half under the Fair
Labor Standards ACT (FLSA).
Employee 9. Contacts Supervisor in accordance with Center Policy I-C-26,

“Leave of Absence”, if scheduled but do not report to work due
to hazardous weather conditions. Employees who are
responsible for staffing essential functions may be disciplined for
unauthorized absences. If inadequate staffing should result
from absences, Supervisors may require employees to work
overtime in accordance with Center Policy I-C-28, “Overtime and
Compensatory Time.”
10. Automatically authorized absences for non-essential personnel

will cease on the cancellation/expiration of an announcement of
reduced services. Thereafter, Center Policy I-c-26, “Leave of
Absence”, will apply.
Department Heads 11. Maintain a current list of all staff members and telephone
numbers designating responsibility for notification of hazardous
weather and reduction of operations.
Satellite Coordinators 12. May contact the Department Head/Executive Director to confirm
the need to reduce operations when dangerous/hazardous is
present in their area.
Designated Staff 13. Have 2 options:

a. May use accrued enforced leave, compensatory
time, or annual leave.
b. May be asked to perform other duties in satellite
office even though transport of consumers is not
possible.
PROCEDURE #: 601
_______________________________________________________________________________O
_______________________________________________________________________________
SUBJECT: BOMB THREAT EFFECTIVE DATE: 02 AUG 04
****************************************************************************************************************
PURPOSE
It is the policy of Jim Taliaferro Community Mental Health Center to assume any bomb threat received as
real. Satellite Staff will adopt this policy as it relates to the Satellite Office. Appropriate consumer/staff
safety and security measures must be followed immediately. Consumer security is the prime
consideration, followed next by staff safety, building, and equipment.
PROCEDURE
WHO WHAT
Secretary/Individual Staff 1. Receives bomb threat message, acquiring as much information

as possible regarding threat and caller (See attachment 1).
.
Satellite Coordinator 2. Receives bomb threat message and information from individual
taking message. Makes decision to evacuate building and/or
initiate search.
3. Notifies local Police Department, Executive Director, and

Director of Program Evaluation at JTCMHC.
Coordinator 4. Notifies other services occupying same building of bomb

threat.
Evacuation of Building
Designated Staff 5. Initiates consumer evacuation, without alerting to bomb

threat message, to a previously arranged designated outside
area.
Satellite Coordinator 7. Designates specific area of satellite to search first, then uses an
assembly area for the temporary safety of consumers if
evacuation is impractical until all can be evacuated or returned
to their places of normal activity.
8. Makes decision as to which staff member will be evacuated

with consumers.
PROCEDURE #: 601
_______________________________________________________________________________O
_______________________________________________________________________________
****************************************************************************************************************
WHO WHAT
Designated Search Team 8. Searches designated area covering each entire satellite.
Staff Searchers 9. Work in two pairs to make a clockwise sweep of entire satellite.
Handling Suspected Explosives 10. Refrains from handling or removing suspected explosives;
Staff Searchers clearing all areas of personnel, if not evacuated, and blocks off
adjacent areas to prevent accidental disturbances of item(s).
Local Police Department 11. Checks suspicious item(s), and if appropriate, contacts the
Explosive Ordinance Disposal (EOD) at Fort Sill.
Explosive Ordinance 12. Issues instructions which will be followed carefully to assure
safety of all consumers/staff.
Designated Staff 13. Renders assistance to EOD, Police Department in traffic control,
communications, tools and equipment, etc., as long as deemed
necessary.
Satellite Coordinator 14. Notifies main Center of all clear and announces all clear when
search is completed and/or dangerous item(s) has been
removed/defused and rendered harmless.
PROCEDURE #: 602
_______________________________________________________________________________O
_______________________________________________________________________________
SUBJECT: FIRE PLAN EFFECTIVE DATE: 02 AUG 04
****************************************************************************************************************
PURPOSE
To provide written guidelines in the event of a fire.
In the event of a fire, or fire drill, all persons will be evacuated from the building. All employees involved
with clients will assist those members in evacuating the building.
PROCEDURE
WHO WHAT
Satellite Coordinator/Director 1. Ensures that evacuation plans and exit routes are posted in
each area. Conducts fire drills quarterly. Ensures that
new/former staff receive orientation regarding location and use
of fire extinguisher, evacuation policy, duties, and exit routes.
.
Any Employee Observing 2. Extinguishes fire when appropriate, such as a trash can fire.
Fire/Smoke
Satellite Coordinator/Director 3. Initiates consumer/staff evacuation to a previously arranged,

Designated outside area.
Employees 4. Closes office/area doors to facilitate containment of fire if time a

allows. Evacuates building to pre-arranged area at a safe
distance form building.
Satellite Coordinator/Director 5. Ensures all consumers and staff are accounted for.
6. Attempts to save clinical, designated personnel, and

administrative records and/or equipment, only if it determined
safe to re-enter building.
7. Announces building is safe for re-entry.

PROCEDURE #: 603
_______________________________________________________________________________O
_______________________________________________________________________________
SUBJECT: SEVERE STORM WARNING/ EFFECTIVE DATE: 02 AUG 04
TORNADO WARNING DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To provide written guidelines in the event of severe weather.
In the event a severe storm warning is sounded and tornado is eminent, consumers will be taken to a
designated Storm Shelter. Otherwise, staff will congregate with consumers in a central room containing
no outside walls, if possible.
PROCEDURE
WHO WHAT
Satellite Coordinator/Director 1. Decides when it is necessary to transport consumers/staff to

designated storm shelter in the building or community.
.
Designated Staff 2. Assists consumers to van and then into storm shelter, when
appropriate.
Satellite Coordinator/Director 3. Makes certain designated storm shelters and addresses are
posted and familiar to staff/consumers.
PROCEDURE #: 700
_______________________________________________________________________________O
_______________________________________________________________________________
SUBJECT: TRAVEL EXPENSES EFFECTIVE DATE: 02 AUG 04
****************************************************************************************************************
PURPOSE
To provide written for obtaining reimbursement for travel expenses.
Staff is reimbursed for use of their own private automobiles when a state vehicle is not available and pre-
approval has been given.
PROCEDURE
WHO WHAT
Staff 1. Keeps record of trips, odometer readings when leaving and on

returning, and reason for travel.
2. Submits all information on Travel Claim Worksheet upon arrival

from travel destination.
Director 3. Reviews claim and signs approving travel expenses.
4. Submits to Accounting Department.

PROCEDURE #: 701
_______________________________________________________________________________O
_______________________________________________________________________________
SUBJECT: WORKSHOP ATTENDANCE EFFECTIVE DATE: 02 AUG 04
****************************************************************************************************************
PURPOSE
Clinicians are encouraged to attend workshops for training that will enhance their skills in working with
those diagnosed with a mental illness, substance abuse, or Co-Occurring disorder.
PROCEDURE
WHO WHAT
Clinician 1. Submits a Workshop/Trip Request form for a desired

workshop, giving dates, destination, title, and description of
workshop, which show relevance to the job..
Director 2. Recommends approval/disapproval and routes to Staff

Development, Accounting Department, and Executive Director.
Clinician will receive the form back with the workshop/trip approved/disapproved. Upon return, the
clinician will follow procedure below.
Clinician 3. Submits information about expenses on Travel Claim

Worksheet, if necessary. (See Travel Expenses Procedure)
4. Submits Workshop Evaluation Report and a copy of

CEU/Attendance Certificate and sends to Staff Development
for input into Staff Development Computer Training Program.
PROCEDURE #: 800
_______________________________________________________________________________O
_______________________________________________________________________________
SUBJECT: GUIDLEINES FOR UNIVERSAL PRECAUTIONS EFFECTIVE DATE: 02 AUG 04
****************************************************************************************************************
PURPOSE
To ensure protection of consumers and staff.
Since medical history of and examination cannot reliably identify all consumers infected with HIV or other
blood-borne pathogens, blood and body fluid precautions should be consistently used for all consumers.
This approach, referred to as “Universal Precautions”, will be used in the care of all consumers.
PROCEDURE
WHO WHAT
All Nursing Staff 1. Wears gloves for touching blood, body fluids, and for
performing venipuncture. Gloves should be changed after
contact with each consumer. Gloves will reduce the incidence
of blood contamination of hands during venipuncture, but they
cannot prevent injuries caused by needles or other sharp
instruments.
2. Takes care to prevent injuries when disposing of used needles

and when handling sharp instruments, and by following these
procedures:
a. Needles will not be recapped after use, purposely

bent or broken, removed from disposable syringes,
or otherwise manipulated by hand.
b. After use, disposable needles, syringes, and other
sharp items will be placed in puncture-proof
containers for disposal. The puncture-proof
containers should be located as close as possible to
the use area.
3. Washes hands and other exposed skin surfaces immediately ad

thoroughly if contaminated with blood or other body fluids.
Hands should be washed immediately after gloves are removed.
4. Health care workers who have exudative lesions or weeping

dermatitis should refrain from all direct consumer care and from
handling consumer care equipment until condition improves.
The implementation of “Universal Precautions” eliminates the need for isolating consumers for “blood and
body fluid precautions,” and prevents consumers from being inadvertently “labeled.”
PROCEDURE #: 801
_______________________________________________________________________________O
_______________________________________________________________________________
SUBJECT: INFECTION CONTROL – HAND WASHING EFFECTIVE DATE: 02 AUG 04
****************************************************************************************************************
PURPOSE
To prevent the spread of infectious diseases.
Policies and procedures are not a replacement for common sense. Hand washing is the single, most
important procedure for preventing the spread of infectious diseases by removing transient microbial
contaminants acquired through recent contact with infected consumers, co-workers, and/or environmental
sources.
PROCEDURE
1. Wet hands under warm, running water, keeping hands lower than elbows. Apply soap (bar, liquid,
granules) or antiseptic soap (Hibiclens).
2. Use friction to clean between fingers, palms, back of hands, wrists, forearms, and clean under
fingernails. Routine hand washing should be vigorously performed for at least ten seconds.
WHO WHAT
All Employees 1. Wash hands after contact with a source that is likely
contaminated, such as blowing nose, personal toileting, etc.
Food Service Workers 2. Wash hands with soap and water prior to handling and/or
preparing food, drink, and utensils.
Medical/ Nursing Staff 3. Wash hands with soap before preparing or serving food/drink,
before and after any aseptic nursing procedure(s), such as
wounds care, lab work, suture removal, etc. Wash hands with
antiseptic soap before and after contact with wounds, after
contact with potentially infected persons/objects, and after any
contact with blood and body fluid(s). Always wear gloves where
indicated.
PROCEDURE #: 802
_______________________________________________________________________________O
_______________________________________________________________________________
SUBJECT: INFECTION CONTROL – EMPLOYEE RISK EFFECTIVE DATE: 02 AUG 04
EXPOSURE DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
PURPOSE
To identify the procedure to be followed in the event of a risk to exposure to blood-borne pathogens.
I. Beginning January 1, 1989, the “Rules and Regulations Governing Risk Exposure” took effect.
This regulatory change was authorized by the Oklahoma State Board of Health under the statutory
authority of Title 630.S.S 1988 Section 1-502.1 (B).
These rules were developed to establish a system of notification for emergency responders,
funeral workers, and heath care workers who, while performing their jobs, sustain risk exposures
which are epidemiologically demonstrated to have the potential for transmitting a communicable
disease.
II. Definitions:
A. Body Fluid: blood or blood product(s), semen, pleural or spinal fluid, or any fluid visibly
contaminated in blood.
B. Communicable Disease: infectious diseases which are transmitted from person-to-person

contact with blood or body secretions, and which may pose an occupational risk to health care
workers. Such diseases include Hepatitis B, Human Immunodeficiency Virus (HIV), Acquired
Immune Deficiency Syndrome (AIDS), menigococcus, measles, pertussis and tuberculosis.
C. Risk Exposure: an exposure which has been epidemiologically demonstrated to pose a risk
for transmission of a communicable disease. Such an exposure would include parenteral
(needle stick or cut), permucosal (mouth-to-mouth resuscitation, splash to eye or mouth),
exposure to blood, or prolonged contact with blood to skin which is chapped, abraded, or
afflicted with dermatitis, or exposure to respiratory secretions.
PROCEDURE
WHO WHAT
Exposed Employee 1. Completes an ODMHSAS Incident Report (JT-1-76) and

submits to appropriate supervisor or charge nurse as soon as
possible after incident.
Clinical Director/Designee 2. Reviews circumstances of exposure to determine of a valid risk

exposure occurred. This review should include, but not limited
to the following:
PROCEDURE #: 802
_______________________________________________________________________________O
_______________________________________________________________________________
SUBJECT: INFECTION CONTROL – EMPLOYEE RISK EFFECTIVE DATE: 02 AUG 04
EXPOSURE DATE REVIEWED: 01 FEB 08
****************************************************************************************************************
WHO WHAT
a. Review of the source consumer’s record and

consultation with consumer’s attending physician to
determine if he or she is known to have a
communicable disease, or if the source consumer
had risk factors for HBV or HIV infection.
b. Testing of the source consumer for HBV or HIV

should be with informed consumer.
2. If a valid risk exposure occurred, refers exposed employee to

the physician of his or her choice for immediate and follow-up
treatment, according to guidelines published by the
Occupational Safety and Health Administration (OSHA) on
“Occupational Exposure to Blood-borne Pathogens” 29 CFR,
Part 1910.1030. These guidelines are outlined in the agency’s
Exposure Control Plan.
All reasonable cost(s) associated with follow-up and testing of the exposed employee shall be applied to
Workers’ Compensation.
Infection Control 3. Determines if Staff are following appropriate prevention

measures to deter infections.
PROCEDURE #: 803
_______________________________________________________________________________O
_______________________________________________________________________________
SUBJECT: INFECTION CONTROL – CLEANING AND EFFECTIVE DATE: 02 AUG 04
DISINFECTION OF CONSUMER CARE DATE REVIEWED: 01 FEB 08
EQUIPMENT
****************************************************************************************************************
PURPOSE
To prevent spread of infection from one consumer to another.
All reusable consumer equipment is to be cleaned and disinfected after each consumer contact. Items
which are intended to be disposable need not be cleaned and should always be discarded after each
single consumer use.
PROCEDURE
WHO WHAT
RN/LPN/PCA Ear Speculums

1. Utilizes disposable ear speculums when available.
2. In the absence of disposable ear speculums, washes with soap
and water, parts which come into direct contact with the
consumer. Soaks washed parts in approved disinfectant for a
minimum of 10 minutes. Rinses parts with clean tap water prior
to drying.
Exam Table
1. Removes and discards used table paper and places into trash
container.
2. Washes top table surface with approved disinfectant.
3. Covers surface with clean table paper.
EKG Machine
1. Removes suction cups, bulbs, wrist and ankle bands, and
metal contacts. Washes these parts with soap and water,
rinses with clean tap water.
2. Utilizing a toothpick or other clean, straight object, clears any
remaining gel from suction cup/bulb.
3. Allows parts to air dry prior to reassembly.
Stethoscope
1. Earpieces are to be wiped clean with alcohol prep before and
after each use.

Outpatient Procedures Master

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OUTPATIENT PROCEDURES

100 CASE MANAGEMENT

200 ADMISSION CRITERIA

300 DOCUMENTATION POLICY

400 DISCHARGE PLANNING

500 JTCMHC ACTING AS REPRESENTATIVE PAYEE FOR THE SOCIAL SECURITY

600 LEAVE WHEN SERVICES ARE TEMPORARILY REDUCED DUE TO HAZARDOUS

700 TRAVEL EXPENSES

800 GUIDLEINES FOR UNIVERSAL PRECAUTIONS

2. Empowers the consumer in obtaining and making use of any

3. Encourages and/or assists the consumer to find activities or

4. Advocates for the consumer in networking with other agencies,

5. Ensures that services are being provided in a community

6. Maintains contact with each consumer as needed with a

2. Encourages the consumer to discuss problems, needs, and

3. Compiles an initial treatment plan with the consumer, based

4. Selects the appropriate best practice modality that provides the

5. Provides counseling services as needed based on

6. Guides consumer in finding appropriate solutions for his/her

7. Provides HIV/AIDS education, counseling, and referral for

2. Upon successful completion of the SASSI, the clinician will

3. Upon receiving referral from DHS Caseworker for the

4. Clinician will complete intake paperwork on each consumer to

5. Upon successful completion of the 8 week group process,

Intake Clinician 1. Clinician will complete intake paperwork on each consumer to

4. Upon first session with each consumer, clinician will administer

5. Clinician will monitor, provide case management, support and

Intake Clinician 5. Clinician will complete intake paperwork on each consumer to

Referring Clinician 1. Obtains a medication appointment for consumer from

2. Appointment slip is provided to consumer with date and time

Nurse 3. Secures charts from medical records for all consumers

4. Upon each visit, records blood pressure, pulse, and weight of

5. Maintains and updates medications as needed.

6. Assesses for side effects, allergies, and contraindications of

Physician 7. Interviews consumer, assesses symptoms, and prescribes

8. Assesses need for co-occurring services, such as group or

Nurse 9. Obtains consumer’s signature on the “Consent for

10. Notes orders and completes paperwork for any laboratory

12. Meets with Medication Assistance Program staff to assess

Medication Assistance 13. Assesses consumer as to whether criteria is met for

14. Turns prescription(s) into pharmacy to receive medication(s).

Nurse 15. Returns all charts to Medical Records by 4:45 p.m.

Clinician 1. Psychological evaluation request is obtained outlining specific

2. Routes request to Psychological services.

Psychologist 3. Contacts consumer for next available appointment.

Doctor, Nurse, or Determination is made to give medication at decided intervals. This

Consumer 3. Prescription is then taken to the pharmacy to be filled.

Nurse 1. Request the procedure on the laboratory request form.

2. Lithium levels require the consumer to have blood drawn in

3. If the procedure requires fasting the consumer should

4. If there is doubt that fasting is necessary, inquire with the

A. HMO’s (Medicaid and Commercial)

Physician 1. Writes laboratory procedures on prescription pad ( to include

Nurse 2. Notes physician’s order(s) in consumer’s chart.

3. Instructs consumer as to requirements of laboratory

4. Instructs consumer as to time frame requirements if

Physician 1. Writes laboratory procedures on “Doctor’s Order” sheet.

2. Writes requested laboratory procedures ( to include

Nurse 3. Notes physician’s orders.

4. Instructs consumer as to requirements of laboratory

5. Instructs consumer as to time frame requirements if

6. Upon receiving laboratory results, he or she directs them to

C. MEDICAID (fee for service)/ CHARITY CARE

Physician 1. Writes laboratory procedures on “Doctor’s Order” sheet.