Title
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Policy Code
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General
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Policies, Procedures, Guidelines, Standards, Protocols and Care Pathways – Definitions
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N/A
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Patient Care
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Policy on Resuscitation of Adult Patients with Tracheostomy Tube or Stoma (Ulster Hospital)
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UCHT/Cl/Pt.Care (01) 2006 (v2)
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Protection of Vulnerable Adults
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UCHT/Cl/Pt.Care (02) 2004
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Labelling of Access Lines to Patients (Ulster, Ards & Bangor Hospitals)
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UCHT/Cl/Pt.Care (03) 2006 (v3)
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Policy for the Accurate Measurement of Blood Pressure
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UCHT/Cl/Pt.Care (04) 2006 (v3)
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Policy Statement : The Mental Health (NI) Order 1986
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UCHT/Cl/Pt.Care (05) 2004
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Breastfeeding Policy Statement
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UCHT/Cl/Pt.Care (06) 2004
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Policy on Breastfeeding in the Community
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UCHT/Cl/Pt.Care (06a) 2006 (V2)
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BCG Vaccination for the Control of Tuberculosis (TB)
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SET/Cl/Pt.Care (07) 2007
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Policy for the Management of Violence and Aggression Including the Use of Restraint
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UCHT/Cl/Pt.Care (08A) 2006
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Policy for Blood Glucose Measurement by Nursing Staff
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UCHT/Cl/Pt.Care (09) 2006
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Policy for the Management of Neurological Dysphagia in Adults
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UCHT/Cl/Pt.Care (10) 2004
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Policy for the Use of Electro Stimulation Therapy for the Treatment of Patients with Incontinence
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UCHT/Cl/Pt.Care (11) 2006 (v2)
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Policy on the Urethral Catheterisation of Male Patients by Trained Nursing Staff
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UCHT/Cl/Pt.Care (12) 2006 (v2)
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Promotion of Continence Policy Statement
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SET/Cl/Pt.Care (13) 2007
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Policy on the Assessment, Treatment and Management of Urinary Incontinence
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SET/Cl/Pt.Care (13a) 2007
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Policy on the Management of Faecal Incontinence
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SET/Cl/Pt.Care (13b) 2007
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Policy for Supply of Incontinence Products
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UCHT/Cl/Pt.Care (13c) 2007
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Policy for Ear Syringing
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UCHT/Cl/Pt.Care (14) 2005
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Policy for the Retention of X-ray Film
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UCHT/Cl/Pt.Care (15) 2005
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Policy for Requesting Portable X-ray Examinations
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UCHT/Cl/Pt.Care (16) 2006 (v2)
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Policy on the Reporting of Radiological Examinations
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UCHT/Cl/Pt.Care (17) 2005
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Vacant
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UCHT/Cl/Pt.Care (18)
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Pressure Ulcer Policy
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UCHT/Cl/Pt.Care (19) 2006 (v3)
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Policy for the Transfer of Patients to Other Hospitals/Facilities
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UCHT/Cl/Pt.Care (20) 2007
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Policy for Consent To Post Mortem Examination
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UCHT/Cl/Pt.Care (21) 2006
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Policy on the Management of Epidural Analgesia (In Non Obstetric Patients)
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UCHT/Cl/Pt.Care (22) 2006 (v3)
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Resuscitation Policy
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UCHT/Cl/Pt.Care (23) 2006
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Resuscitation Training Policy
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UCHT/Cl/Pt.Care (24) 2006
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Policy on Caring for Patients with Wounds
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UCHT/Cl/Pt.Care (25) 2006 (v3)
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Nursing Policy on Sharp Debridement of Devitalised Tissue above the Level of Viable Tissue
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UCHT/Cl/Pt.Care (26) 2006 (v2)
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Policy for Consent to Examination, Treatment or Care
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UCHT/Cl/Pt.Care (27) 2004
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Policy for the Management of Intrathecal (IT) Delivery of Analgesics in Palliative Patients
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UCHT/Cl/Pt.Care (28) 2006
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Policy for Venepuncture by Nursing Staff/Phlebotomists
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UCHT/Cl/Pt.Care (29) 2006 (v3)
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Policy for Intravenous Cannulation by Nursing Staff
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UCHT/Cl/Pt.Care (30) 2006
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Policy for Internal Transfer of Patients/Clients
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UCHT/Cl/Pt.Care (31) 2006
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Policy on ‘Do Not Attempt Resuscitation (DNAR)’ Orders
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UCHT/Cl/Pt.Care (32) 2006
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Advocacy Policy
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UCHT/Cl/Pt.Care (33) 2006 (v2)
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Policy Statement on Seclusion
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UCHT/Cl/Pt.Care (34) 2005
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Policy on Advance Directives (Living Wills)
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UCHT/Cl/Pt.Care (35) 2006 (v3)
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Anaphylactic Shock Policy - Acute and Community Settings (Adults and Children)
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UCHT/Cl/Pt.Care (36) 2006 (v3)
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Policy for the Referral Criteria to District Nursing Services
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UCHT/Cl/Pt.Care (37) 2006 (v4)
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Radiation Safety Policy
(Excluding Community Dental Services in NI)
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UCHT/Cl/Pt.Care (38) 2006 (v2)
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Time Out Policy
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UCHT/Cl/Pt.Care (39) 2005
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Blood Transfusion Policy
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UCHT/Cl/Pt.Care (40) 2006
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Policy for Emergency Referrals to Maternity
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UCHT/Cl/Pt.Care (41) 2005
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Policy for the Management of the Pregnant or Post-Partum Woman in the Accident & Emergency Department
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UCHT/Cl/Pt.Care (42) 2006 (v2)
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Policy on Pregnancy Loss, Stillbirth (N.I.) Order, 1992 and Neonatal Death
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UCHT/Cl/Pt.Care (43) 2006 (v2)
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Vacant
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UCHT/Cl/Pt.Care (44)
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Vacant
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UCHT/Cl/Pt.Care (45)
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Policy for Point of Care Testing (POCT)
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UCHT/Cl/Pt.Care (46) 2005
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Vacant
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UCHT/Cl/Pt.Care (47)
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Policy for the Management of Head-Injured Patients
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UCHT/Cl/Pt.Care (48) 2006
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Escort Policy
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UCHT/Cl/Pt.Care (49) 2006
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Referral to the Day Obstetric Unit at the Ulster Hospital
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UCHT/Cl/Pt.Care (50) 2006
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Management of Childbearing Women Identified with Mental Health Risk Factors
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UCHT/Cl/Pt.Care (51) 2006
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Policy on Fetal Heart Rate Monitoring Outside the Maternity Unit
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UCHT/Cl/Pt.Care (52) 2006
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Policy & Procedure for Administration of Medication Subcutaneously Via a Syringe Driver
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UCHT/Cl/Pt.Care (53) 2006 (v2)
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Policy on Special Observation of Mental Health Inpatients
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UCHT/Cl/Pt.Care (54) 2006
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Policy & Associated Guidelines for Care of Patients with Lower Limb Arterial Ulceration, Venous Ulceration and Eczema
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UCHT/Cl/Pt.Care (55) 2006 (v3)
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Policy for Anomaly Scanning
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UCHT/Cl/Pt.Care (56) 2003
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Vacant
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UCHT/Cl/Pt.Care (57)
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Policy and Procedures on Permanence
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UCHT/Cl/Pt.Care (58) 2004
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Policy on the Management of Patient Controlled Analgesia (P.C.A.) (persons aged 14 and over)
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SET/Cl/Pt.Care (59) 2007
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Policy on the Care and Maintenance of Central Lines
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UCHT/Cl/Pt.Care (60) 2006 (v2)
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Chaperone Policy
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UCHT/Cl/Pt.Care (61) 2005
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Vacant
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UCHT/Cl/Pt.Care (62)
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Policy on Access to Intensive Care for Children and Young People
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UCHT/Cl/Pt.Care (63) 2006
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Policy on Bowel Care for Adults with Established Spinal Cord Lesions
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UCHT/Cl/Pt.Care (64) 2006
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Policy for the Typing of Scheduled Operating Theatre Lists
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UCHT/Cl/Pt.Care (65) 2007
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Policy on Sending for Patients Ulster Site
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UCHT/Cl/Pt.Care (66a) 2007
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Policy on Sending for Patients Ards Site
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UCHT/Cl/Pt.Care (66b) 2007
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Policy for Patient “Check In” Procedure
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UCHT/Cl/Pt.Care (67) 2007
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Policy and Procedure for Correct Site Surgery
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UCHT/Cl/Pt.Care (68) 2007
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Policy for Demonstration of Training and Competence for Medical Staff Undertaking New Techniques
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UCHT/Cl/Pt.Care (69) 2007
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CANCER
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Policy for Intravenous Cytotoxic Agents Administration (Nursing Staff)
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UCHT/Cl/Cancer (01) 2004
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Treatment of Extravasation of Intravenous Cytotoxic Drugs
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UCHT/Cl/Cancer (02) 2006 (v2)
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Vacant
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UCHT/Cl/Cancer (03)
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MEDICINES
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Medicines Policy for the Prescribing, Supply, Administration, Storage and Disposal of Medicines
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UCHT/Cl/Med (01) 2006 (V1)
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Policy for the Use of Oral Methotrexate
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UCHT/Cl/Med (02) 2006
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Policy & Procedure on Dealing with Patients found to be in Possession of Unauthorised Drug(s) or other Suspicious Substance(s)
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UCHT/Cl/Med (03) 2005
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Policy on the Generic Prescribing of Medicines
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UCHT/Cl/Med (04) 2006
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Medicines Management Strategy
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UCHT/Cl/Med (05) 2006
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Vacant
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UCHT/Cl/Med (06)
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Vacant
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UCHT/Cl/Med (07)
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Policy for the Administration of Intrathecal Chemotherapy
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UCHT/Cl/Med (08) 2005 (v3)
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Policy Relating to the Management of Strong Potassium Injections
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UCHT/Cl/Med (09) 2006
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Policy for the Documentation of Allergy Status
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UCHT/Cl/Med (10) 2005
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MANAGEMENT
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Policy for Notifying a General Practitioner of a Patient’s Death
`
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UCHT/Cl/Mge (01) 2006 (V3)
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Interim Policy on Research Governance Process
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UCHT/Cl/Mge (02) 2005
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Wheelchair Lending Policy for Hospital Inpatients
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UCHT/Cl/Mge (03) 2004
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Policy for Nurse Staffing
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UCHT/Cl/Mge (04) 2006 (v3)
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Policy for the Management of Hospital Waiting Lists (Acute Hospital)
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UCHT/Cl/Mge (05) 2004
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Guidelines for Nursing Staff Releasing Patient Information
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UCHT/Cl/Mge (06) 2006
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Policy for the Discharge of Patients from the Ulster Hospital
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UCHT/Cl/Mge (07) 2006
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Breaking Bad News Policy
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UCHT/Cl/Mge (08) 2004
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Policy for the Management of Physical Health Emergencies (Acute & Community Hospitals)
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UCHT/Cl/Mge (09) 2006
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Policy on Dealing with the Death of a Patient/User of a Service
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UCHT/Cl/Mge (10) 2006
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Policy on the Management of Bereavement
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UCHT/Cl/Mge (11) 2006
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Policy for the Provision of Patient/Client Single Sex Accommodation
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UCHT/Cl/Mge (12) 2006 (v3)
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Policy for Nursing Student /Midwife Placements
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UCHT/Cl/Mge (13) 2005
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Hospitals Admission Policy
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UCHT/Cl/Mge (14) 2006 (v3)
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Policy for Supporting Newly Qualified Nursing Staff and Those Returning to Nursing Both in Adult and Midwifery Practice
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UCHT/Cl/Mge (15) 2006
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Policy for Inpatient and/or Day Case/DNAs/Cancellations
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UCHT/Cl/Mge (16) 2004
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Policy on Communication Between Nursing and Medical Staff
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UCHT/Cl/Mge (17) 2005
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Policy Statement: Supervision, Management and Support of Staff
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UCHT/Cl/Mge (18) 2006 (v3)
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Nurse Bank Operational Policy
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UCHT/Cl/Mge (19) 2006
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Protocol for the Use of Bank and Agency Nursing Staff within the Ulster Community & Hospitals Trust
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UCHT/Cl/Mge (19b) 2005
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Policy for Nurses Registration with NMC
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UCHT/Cl/Mge (20) 2004
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Policy for Referral Into Trust Services Referral Policy
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UCHT/Cl/Mge (21) 2006
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Policy on Health Care Record Content
(Acute Hospital Settings)
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UCHT/Cl/Mge (22) 2002
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Policy on Health/Social Care Record Content: Community Records
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UCHT/Cl/Mge (22a) 2006 (v2)
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Policy on Management of Potential Organ and Tissue Donors
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UCHT/Cl/Mge (23) 2005 (v3)
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Policy for the Removal of Deceased Persons from Wards within the Ulster Hospital
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UCHT/Cl/Mge (24) 2004
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Policy on the Development and Co-ordination of Care Pathways
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UCHT/Cl/Mge (25) 2006
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Medical Devices Policy
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UCHT/Cl/Mge (26) 2007
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Policy for Return or Disposal of Organs, Limbs or Digits
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UCHT/Cl/Mge (27) 2006 (v3)
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Policy on Obtaining and the Recording of Patient/Client Information on Admission/Acceptance into Trust Services
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UCHT/Cl/Mge (28) 2006
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Chain of Command/Reporting Mechanism Policy
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UCHT/Cl/Mge (29) 2006
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Policy for the Management of Waiting Lists for Allied Health Professions
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UCHT/Cl/Mge (30) 2006 (v2)
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Policy for Case Closure
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UCHT/Cl/Mge (31) 2006
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Policy and Procedure on Photography and Video Recordings of Patients: Confidentiality and Consent, Copyright and Storage
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UCHT/Cl/Mge (32) 2006 (v2)
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Cancellation of Theatre Lists Due to Annual Leave or Study Leave
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UCHT/Cl/Mge (33) 2003
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Managing Waiting Times ‘Treating Non Urgent Patients in Turn’
(Elective Inpatient and Daycase Patients)
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UCHT/Cl/Mge (34) 2004
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Policy for Periodic Testing of Benchtop Sterilisers
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UCHT/Cl/Mge (35) 2004
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Policy for Instrument Traceability
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UCHT/Cl/Mge (36) 2004
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Policy on the Management of Flexible Endoscopes
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UCHT/Cl/Mge (37) 2005
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Policy for Use of Emergency Theatre (Ulster Hospital)
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SET/Cl/Mge (38) 2007
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Policy Statement for Decontamination of
Re-Usable Surgical Instruments
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UCHT/Cl/Mge (39) 2005
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Interim Policy and Procedure for Implementation of Annual Appraisal for Medical Staff (for Medical Staff in Previous UCHT)
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UCHT/Cl/Mge (40) 2007
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Traceability of Blood and Blood Products Issued by the Blood Bank at the Ulster Hospital
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SET/Cl/Mge (41) 2007
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Policy For Handling Forensic Items
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UCHT/Cl/Mge (42) 2006
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