Training Manual - Golden Gate Urgent Careintranet.goldengateurgentcare.com/.../GGUC_Training_Manual...ver_2.pdf · Copyright© 2012. NMN Consultants. All rights reserved NMN Consultants

Copyright© 2012. NMN Consultants. All rights reserved NMN Consultants. No part of this document may be produced in any form without the written consent of NMN Consultants.

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Training Manual


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Golden Gate Urgent Care Training Manual

All rights reserved. No part of this work may be reproduced or transmitted in any form or by any means, electronic or mechanical, without the permission in writing from the publisher.

DISCLAIMERNATIONAL MED NETWORKS

The content of this publication is for the purposes of guidance and information. NMN Consultants does not assume any responsibility for any injury or damage to persons or property arising out of any claim, including but not limited to negligence arising out of the performance of any of the methods, guidelines or ideas contained in this manual.

The authors, editors and publisher are not responsible for errors or omissions, therefore make no warranty, expressed or implied to the currency and accuracy of the contents of this publication.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information retrieval system without permission in writing from NMN Consultants.


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ContentsSECTION 1 ......................................................................................................................................................1-1Training Manual Instructions ......................................................................................................................................... 1-2Training Policies ............................................................................................................................................................... 1-2Designated Trainers ......................................................................................................................................................... 1-2Nursing General Policies and Terminology .................................................................................................................. 1-3Biohazard and Sharps Protocol ...................................................................................................................................... 1-51. New Employee Training Checklist ............................................................................................................................. 1-72. Chart Documentation ................................................................................................................................................. 1-83. Obtaining Vital Signs ................................................................................................................................................... 1-93.5 Obtaining Orthostatic Vital Signs .......................................................................................................................... 1-114. Performing Vision Testing ........................................................................................................................................ 1-125. Performing a Dipstick Urinalysis with Clinitek ..................................................................................................... 1-136. Performing a Strep Test ............................................................................................................................................. 1-147. Performing Pulse Oximetry ...................................................................................................................................... 1-158. Wound Management ................................................................................................................................................. 1-168.5 Wound Prep Post Test .............................................................................................................................................. 1-179. Dispensing Medication From DRX System ............................................................................................................ 1-1810. Performing a Urine HCG ........................................................................................................................................ 1-1911. Performing a Mono Spot Test ................................................................................................................................. 1-2012. Administering Intradermal Injections .................................................................................................................. 1-2113. Instrument Cleaning ................................................................................................................................................ 1-2214. Instrument Identification Test ................................................................................................................................ 1-2315. New Employee Training Checklist ......................................................................................................................... 1-2516. Performing an Ear Irrigation .................................................................................................................................. 1-2617. Eye Irrigation ............................................................................................................................................................ 1-2718. Preparing for a Slit Lamp Exam / Eye Injury ........................................................................................................ 1-2819. Administering a Nebulizer Treatment ................................................................................................................... 1-2920. Administering IM Medication ............................................................................................................................... 1-3021. Administering Subcutaneous Injections ............................................................................................................... 1-3122. Administering Allergy Medications ...................................................................................................................... 1-3223. Obtaining 12-Lead EKG .......................................................................................................................................... 1-3324. Administering Oxygen ............................................................................................................................................ 1-3425. Performing Blood Glucose Test.............................................................................................................................. 1-3526. Handling Patient Call-Backs ................................................................................................................................... 1-3627. Scheduling Tests ....................................................................................................................................................... 1-3728. Physical Therapy Referrals ...................................................................................................................................... 1-3829. Orthopedic Referrals ............................................................................................................................................... 1-3930. New Employee Training Checklist ......................................................................................................................... 1-4031. Reading TB Test Results .......................................................................................................................................... 1-4132. Obtaining Blood for Lab Testing ............................................................................................................................ 1-4233. Preparing for Casting or Splinting ......................................................................................................................... 1-4434. Preparing for Joint or Soft Tissue Injections ........................................................................................................ 1-4635. Preparing for Incision and Drainage ..................................................................................................................... 1-4736. Preparing for a Pelvic Exam .................................................................................................................................... 1-4837. Completing Daily Chart Checks ............................................................................................................................ 1-4938. Clinical Opening Procedures ................................................................................................................................. 1-5039. Clinical Closing Procedures ................................................................................................................................... 1-5140. Down-Time Procedures .......................................................................................................................................... 1-5241. Intravenous Infusion ................................................................................................................................................ 1-53


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42. Administering IV Medications ............................................................................................................................... 1-55Item Description Quiz ................................................................................................................................................... 1-56Injections and Vaccines ................................................................................................................................................. 1-59Changing for Radiographic Exams .............................................................................................................................. 1-60Training Log Sign Off for Employee ............................................................................................................................ 1-61Patient Flow ..................................................................................................................................................................... 1-63How to Administer IM Injections ................................................................................................................................ 1-65How to Administer SQ Injections ................................................................................................................................ 1-66Fire Safety Training Powerpoint ................................................................................................................................... 1-67


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Training Manual

SECTION 1


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Training Manual InstructionsIt is the goal of Golden Gate Urgent Care to provide the best possible care for our patients, utilizing the varied talents of our staff regardless of their clinical background. Therefore, we strive to provide a thorough training program for all of our new staff members in order to assist them in learning new skills as well as refining the skills they possess. Further, we provide continuing training and education to help our clinicians maintain proficiency. We feel that successful learning is achieved by observation, “hands on” repetition, and questioning. We make every effort to provide a patient and professional learning environment.

Each new clinical staff member will be assigned to a senior staff member during the first three (3) months of full-time employment (a longer period may be required for those employees working less than full-time). This senior staff member will be a primary resource for learning new skills, addressing questions of policy or procedure, and signing off on the new employees training manual. The new staff member should direct all questions to this assigned trainer. If the assigned trainer is not available, then the Clinic Coordinator of the respective clinic in which the new employee is working will guide training and questions.

The following manual is divided into 3 consecutive monthly sections. Each training period (1 month intervals) has a list of skills that are expected to be learned during that month of training. The individual skill sheets are meant as a guide for training, not to replace actual observation and “hands on” experience. When a new staff member feels that they have learned a certain skill, they should perform the skill under the observation of their trainer. The trainer will then “sign off ” on the skill sheet. The original “signed” skill sheet will then be sent to Director of Clinical Services and the new staff member will maintain a copy of their training manual.

The new staff member should remember to keep the training manual with them during each shift they work and when working from one clinic to another. The training manual provides documentation of skills obtained and assists the clinic coordinator or QV staff with assigning duties appropriately to the new staff member.

Remember that the training manual is only a guide to the many policies and procedures that may be required of a clinical staff member. Learning is an on-going process. Policy, protocol and procedure can adjust as new developments in medicine occur and as the needs of our patient or corporate clients charge.

Training Policies Golden Gate Urgent Care employs staff for the nursing department with a variety of clinical experience. Staff members are expected to learn and become proficient at all clinical tasks regardless of their background, with the following exceptions:

1. Performing IV insertion2. Administering IV medications3. Performing pediatric phlebotomy

Only staff members that have demonstrated competency and have the desire shall perform these skills. In addition, these skills require yearly demonstration of proficiency due to the infrequency of performance.

Golden Gate Urgent Care reserves the right to prohibit any staff member from the performance of a skill if there are concerns regarding the staff member’s ability to perform the skill. Complaints against a staff member’s skill performance will be investigated by the Clinic Coordinator and the Director and a determination may require retraining.

Designated Trainers Each new staff member shall be assigned a primary trainer. Every effort will be made to schedule training to


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coincide with the designated trainer’s schedule, however when this is not possible, the new staff member can train with another trainer from this list.

Further, any questions or assistance needed during the 90-day training period must only be addressed to either your designated trainer, Clinic Coordinator or Director of Clinical Services to assure continuity of training.

Golden Gate Urgent Care Nursing General Policies & TerminologyBlood Borne Pathogen Training: All staff members must complete OSHA Blood Borne Pathogens training prior to working as a clinical staff member. Refresher training is required yearly thereafter. This training is conducted in-house.

Booties: All patients presenting to our facilities that have overtly soiled shoes/boots should be given blue covers to place over their shoes when they are brought back to the treatment area. Worker’s Compensation patients are frequently the most problematic due to mud, grease, or solvents.

Clinical Assistants: All staff members, regardless of title (RN, LPN, CMA, MA, PCT, Paramedic) working within the nursing department (Non-licensed staff members may not refer to themselves as “nursing staff ” because of legal implications).

Clinic Coordinator: The Clinic Coordinator is the senior clinical staff member (RN or LPN) for each respective clinic. The Clinic Coordinator oversees all aspects of clinic operation with the exception of direct physician care of the patient. All problems or issues within the facility should be initially directed to the Clinic Coordinator. Currently, the following personnel are Golden Gate Urgent Care Clinic Coordinators: Kurt Kunzel, M.D.

Director of Clinical Services: The Director of Clinical Services oversees all clinical nursing function. She/he is responsible for generating the staff work schedule and is the reference person for all problems and issues involving patient care, staffing, personnel issues, and clinical services beyond the scope of the individual clinic coordinators who report her/him. The Director of Clinical Services is a member of the Leadership Team and reports to the board of directors. Currently, the Director of Clinical Services is Kurt Kunzel, M.D.

Assistant Director of Clinical Services: The Assistant Director of Clinical Services assists the Director with overseeing all clinical nursing function. She is also a reference for all problems and issues involving patient care, staffing, personnel issues, and clinical services beyond the scope of the individual clinic coordinators. The Assistant Director of Clinical Services is a member of the Leadership Team and reports to the Director of Clinical Services. Currently the Assistant Director of Clinical Services is Mary Jane Connell.

Down Time: When patient flow is minimal, staff members are expected to complete certain tasks that maintain the appearance and function of the facility. These tasks include, but are not limited to the following: room stocking, cleaning exam tables, cleaning stock cabinets and rooms, wiping down walls, chart audits, assisting with other departments, other tasks as assigned by senior nursing staff member. (Refer to the listing of down-time activities located in the “other guidelines” section of this manual).

Exposure Control Plan: Reference manual that directs the procedures for handling any exposure incident for a staff member.

Exposure Treatment Policy & Counseling Protocol: Reference manual that addresses the management of any


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exposure (non-staff member).

Fast Track: Fast track refers to patients not needing the physician (e.g., injections only, Tb skin tests). Priority should be given to these patients over those waiting to see the physician whenever possible.

Leaving Early: On occasion, if the patient flow is less than expected, the senior clinical staff member may send staff members home early. Precedence will be for those staff members scheduled for or nearing overtime, then to the staff members in order of shift start time. If a staff member requests to leave earlier than their scheduled time, this will be determined by the Clinic Coordinator or senior clinical staff with careful attention to patient flow. No staff member should be allowed to leave early prior to checking patient flow and staffing needs at the other facilities. In general, leaving more than one (1) hour early is unacceptable.

Meal Breaks: Meal breaks are 30 minutes in duration and may be taken on the clock so long as the staff member remains on Golden Gate Urgent Care property. Meal breaks are taken in order of start of shift, (e.g., 7:30 nurse begins followed by 8 am nurse and so forth) and may be affected by patient flow.

Nursing Policy and Procedure Manual: Reference manual located in each facility that contains guidelines for clinical procedures and operations. This manual is frequently updated and should be reviewed on a regular basis.

Patient Call Backs: It is Golden Gate Urgent Care’s policy that all patients will be called from our office within three (3) days following their visit to check on their condition. Any questions or concerns stated by the patient during the call should be documented and referred to the physician or PA on duty.

Patient Flow: Golden Gate Urgent Care strives to provide excellent care in an expedient manner. Every effort should be made to have the patient evaluated and treated within an hour (although more complex injuries or illnesses may require more time). While it is primarily the responsibility of the QV person to manage patient flow, all staff members should be attentive to performing whatever function (e.g., ordering x-rays, performing tests, performing drug screens, preparing traumas, etc.,) will result in more expedient care for our patients. ***Please refer to the patient flow diagram located in the appendix of this manual ***

Patient Information Sheets: Each clinic has a file cabinet containing medical information sheets that can be given to the patient to provide further information or instruction on their condition or follow-up.

Patient Phone Calls: All phone calls, either to or from a patient, must be documented. ***Please refer to the appendix for a sample of the patient phone call form*** Patients calling in to the clinic for questions, refills, illness, or lab results should have their calls returned the same day. All questions about care or medication must be referred to the physicians or nurse on duty. Other staff members may not give out medical advice!

Patients that contact Golden Gate Urgent Care and do not have an active chart (i.e., questions; friends/families of providers, etc.,) are to be documented on a “general call record” with the resulting advice and/or actions. Pediatric Patient Call-Back: All pediatric patient visits will be followed up with a call back within one business day to check on the well-being of the patient. These charts are designated by a “P” next to the patient’s name on the chart and should be pulled from the regular callbacks daily.

Personal Hygiene: It is expected that all clinical staff members practice appropriate personal hygiene while working their assigned shift. Strong perfume, aftershave, or cologne is not permitted due to the potential for respiratory problems for our patients. In addition, jewelry and nails should be kept to a minimum to avoid injury a patient.

Private Phone Calls: Personal phone calls should be limited to the staff member’s mealtime. Personal cell phones,


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except those belonging to management staff, should be turned off or muted during work hours.

Proficiency: Proficiency of skills is determined by designated trainers. No clinical staff member shall perform any clinical service without having first been trained and signed off by their designated trainer.

QV: QV stands for quality verification staff member. This is a staff member that has demonstrated proficiency in clinical skills and Golden Gate Urgent Care policy and procedure. The QV person is responsible for checking and detecting errors on all drug screens, physical exams, and pre-employment paperwork prior to discharge of the patient. The QV is responsible for directing patient flow in the absence of the Clinic Coordinator.

Site Assistant: The clinical site assistant is responsible for overseeing clinical function and maintenance in the absence of a Clinical Coordinator. The site assistant is responsible for managing medical supply and medication inventory. The site assistant reports directly to the Director of Clinical Services.

Smoking: Smoking is only allowed during breaks (see break policy) in the employee’s personal vehicle. No smoking is allowed in company vehicles or on company property at any time. Staff that has contact with patients must not have the odor of cigarette/cigar smoke on their clothing. Violation of this policy will result in disciplinary action according to company policy.

Training Period / Trainers: All new employees will complete a six (6) week training period. During this time, the new employee will be assigned a designated trainer; generally a staff member that has demonstrated proficiency in the required skills and knowledge of policies and procedures. The new staff member will also be issued a manual to document skills attained and to maintain as a reference manual following completion of the training period.

Uniforms: Uniforms for clinical staff – pants and tops may only be Golden Gate Urgent Care logo (or approved color). Shoes must be predominantly white and clean. Lab jackets, if worn – must be of approved color with Golden Gate Urgent Care logo provided by Golden Gare Urgent Care.

Work Schedules: Work schedules are created by the Clinic Supervisors with attention to the requests of the staff appropriate to adequate staffing. Time-off requests are required by the appointed day each month. Requests made after the deadline will not be honored. Staff members are expected to arrive for scheduled shifts on time. A 6 minute window is allowed before incurring “tardy”. Staff members should not clock in earlier than 10 minutes prior to their scheduled shift unless requested by senior staff to assist with patient flow. In addition, staff members scheduled to “close” a clinic must be prepared to remain to complete treatment, paperwork, and discharge of all patients remaining in the facility after posted hours.

Biohazard and Sharps ProtocolGolden Gate Urgent Care strives to comply with all OSHA mandated regulations in regards to the disposal of biohazard waste and contaminated sharps. Any deviations from accepted practices can result in disciplinary action up to and including termination.1. Eating or drinking is not permitted outside of the break room. Use of personal care items is not permitted

outside the break room or restroom.2. Personal protective equipment must be used for any contact with broken skin, or where contact with body

fluids is possible. Gloves must be worn for all direct patient contact or when handling samples for the centrifuge.

3. Eye protection must be worn when a splash or splatter hazard exists.4. Staff should wear protective gowns or lab jackets when performing phlebotomy or managing open trauma.5. All sharps (e.g., needles, scalpels, disposable instruments, suture needles, curettes, foreign bodies, nail pieces

or bone fragments) must be disposed of into approved sharps container.


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6. Recapping of needles is not permitted.7. Sharps containers should be closed and sealed when they are ¾ full. They are to be checked once weekly.8. Non-sharp waste contaminated by blood or body fluid should be disposed of into red-biohazard bags or

larger biohazard trash containers.9. Biohazard trash should be removed to transport containers weekly or as they become ¾ full. Never attempt

to compress this trash!10. All used instruments are considered contaminated and must be sterilized. 11. When transporting dirty instruments, they must be placed in a puncture resistant container.12. When placing instruments in cold sterilization or scrubbing instruments after they soak, eye protection and

gloves must be worn.13. Always confirm with the physician or PA that suture needles have been disposed of prior to cleaning

following trauma.14. All work surfaces should be decontaminated following any spill of blood or potentially infectious material as

well as at the end of the work shift.15. All exposure incidents must be reported to your supervisor immediately!

Questions regarding policy and protocol for handling blood borne pathogens and biohazards should be directed to your Clinic Coordinator or the Director of Clinical Services.


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1. New Employee Training Checklist

First Month

The following list of training items must be completed and signed off by a designated trainer within the first 30 days of full-time employment. Any deviation or delays should be noted below.

1. Review of Policies2. Chart Documentation3. Proficiency in Obtaining Vital Signs/ Orthostatic4. Performing Vision Testing (Snellen) & Titmus5. Performing Urinalysis (dipstick UA)6. Performing Strep Test7. Performing Pulse Oximetry8. Wound Management/ Trauma Preparation9. Medication Dispensing10. Performing Urine Pregnancy Testing (HCG)11. Performing Mono Spots12. Performing Intradermal Injections (TB Mantoux)13. Instruments Cleaning/ Sterilization14. Completion of Instrument Identification Test15. Bloodborne Pathogens Training

Comments:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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2. Chart DocumentationIt is the policy of Golden Gate Urgent Care that every patient evaluated at our facilities will have a chart created and thorough documentation recorded for every visit or patient contact.

The hallmark of proper documentation include, but are not limited to, full vitals, chief complaint, notation of current medications and allergies, time in/out, documentation of injections, correct coding, and correct charges as applicable. History and, physical treatment plan, and procedure notes are primarily the responsibility of the provider; however, clinical staff should note completion of these areas prior to patient discharge.

Full vital signs include the following:1. Pulse2. Respirations3. Blood Pressure (children under 12 or as appropriate to body size or chief complaint)4. Temperature5. Height/Weight (children under 12 or as appropriate for chief complaint)6. Visual acuity (ALL eye complaint or head injuries)7. Last menstrual cycle (females over 12)

Any medication the patient is currently taking (both prescription and/or OTC) must be listed.

The accepted rule of documentation is that “if it is not documented – it was never done”! It is a requirement that staff members must initial all of their documentation (interjections, charges, medications, discharge instructions). It is also a requirement that their initials, signature, and PV identification number are correctly documented.

Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee signature: ______________________________

Trainer signature: ______________________________

Date of successful completion: ____________________


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3. Obtaining Vital SignsIt is the policy of Golden Gate Urgent Care that every patient presenting for treatment must have vital signs obtained and properly documented on the PiVoT.

Patients over the age of 12 must have full vitals recorded (e.g., pulse, temp, B/P, respiratory rate). Children under the age of 12 must have pulse, temp, respiratory rate and weight recorded. Blood pressure should be obtained as necessary according to chief complaint.

Performance Checklist (Blood Pressure)( ) Gather the appropriate size blood pressure cuff( ) Remove or repositions clothing to expose area where cuff is applied( ) Extend are with palm facing upward( ) Apply cuff 1-2 inches above inner aspect of the elbow with the bladder over the brachial artery( ) Palpate the brachial artery with fingertips( ) Tighten the valve and inflates cuff until pulse disappears( ) Deflate the cuff( ) Place bell of stethoscope over point where palpated pulse disappeared ( ) Re-inflate cuff to 30mmHg above point where palpated pulse disappeared( ) Release valve slowly ( ) Note changes in sounds with the calibrations on gauge( ) Remove cuff ( ) Record value of when pulse is first heard and last heard as systolic and diastolic respectively( ) Communicate unusual findings to Provider

Expected Norms: Average Upper Limits 1 year 95/65 6-9 years 100/65 119/79 10-13 years 110/65 124/84 14-17 years 120/80 134/89 18 + 120/80 140/90

Performance Checklist (Pulse)( ) Position patient comfortably( ) Place finger tips of first and second fingers on the inner surface of the wrist( ) Compresses artery gently on the thumb side of the wrist adjacent the bone( ) Counts the pulse for 30 seconds if regular, or full minute if irregular( ) Records pulse rate noting irregularities( ) Communicates any unusual findings to the Provider

Expected Norms: Average Range Newborn 140 120-160 1-12 months 120 80-140 1-2 years 110 80-130 2-6 years 100 75-120 6-12 years 95 75-110 12-18 80 60-100 Adult 80 60-100

Performance Checklist (Respiratory Rate)


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( ) Position patient comfortably( ) Unobtrusively observe patient’s respiratory rate while seeming to perform other activity( ) Counts respiratory rate for minimum of 30 seconds or 1 full minute if pattern deviates from normal( ) Record respiratory rate on chart, noting any irregularities( ) Communicate any unusual findings to Provider

Expected Norms: Average Range/ minute Newborn 30-80 Early Childhood 20-40 Late Childhood 15-25 Adult male 14-18 Adult female 16-20

Comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainer Signature: ___________________________________________________________________________

Trainers Signature: __________________________________________________________________________

Date of Successful Completion: ________________________________________________________________


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3.5 Obtaining Orthostatic Vital SignsDefinition: Orthostatic pressure changes are related to a change in the systolic pressure greater than 10mmHg when taken after a patient changes body position e.g., lying, sitting, or standing.Although a physician can order orthostatics, the competent nursing staff member may obtain these vital signs during an initial assessment if there is a suspicion of fluid loss, or if the patient complains of other related symptoms such as weakness or dizziness with the change of position.

Performance Checklist( ) Confirm the written order ( ) Gather appropriate size blood pressure cuff( ) Explain procedure to patient ( ) Place patient in comfortable lying position( ) Allow 1 full minute between position changes ( ) Obtain a blood pressure and radial pulse( ) Record measurements * see diagram below( ) Assist patient to sitting position, legs dangling( ) Allow 1 full minute for postural change( ) Obtain a blood pressure and pulse ( ) Record measurements * see below( ) Assist patient to standing position. Use caution and maintain contact with patient until patient is able to stand unassisted ( ) Allow one (1) full minute before postural change( ) Obtain blood pressure and pulse( ) Record measurements * see below ( ) Assist patient back to position of comfort( ) Inform physician of any significant blood pressure or pulse variations

Vital signs should be recorded as shown below B/P Pulse X X X X X X

Comments:____________________________________________________________________________________________________________________________________________________________________________________

Trainee signature: ___________________________________________________________________________

Trainer signature: ___________________________________________________________________________

Date of successful completion: _________________________________________________________________


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4. Performing Vision TestingIt is the policy of Golden Gate Urgent Care that a visual acuity will be performed on all patients with any complaint related to eye(s).

( ) Have the patient stand at the designated 20 foot mark( ) Instruct the patient to cover one eye (either with the eye occluder or gently with their hand)( ) Patient should be instructed to attempt to read the 20/40 line to begin( ) Have the patient continue reading the chart until 2 or more misreads occur. The last line correctly read with one or less missed is recorded( ) Repeat the process with the other eye. (Note if the acuity is with or without corrective lenses)( ) Record results

Comments:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee signature: _________________________

Trainer’s signature: ________________________

Date of successful completion: _______________


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5. Performing a Dipstick Urinalysis w/ ClinitekCollection and testing of a urinalysis should be performed with the order of a physician. Although not an invasive procedure, since it involves obtaining a body fluid universal precautions apply.

Performance Checklist( ) Confirm the written order( ) Gather necessary equipment to patient’s room (urine cup and benzalkonium wipe)( ) Explain testing procedure.(remind patient to attempt to collect midstream urine).( ) Direct patient to bathroom( ) Put on gloves( ) Take specimen from patient( ) Remind patient to wash hands( ) Place on towel or covered flat surface( ) Label specimen (patient name, room #)( ) Obtain UA dipstick from container and dip into specimen (Use 10SG for P2 and UA’s) (Use PRO’s for all suspected UTI’s)( ) Place dipstick face up on the black tray of the Clinitek device( ) Press green button on either side of the display to initiate test( ) Obtain result printout( ) Remove gloves and wash hands( ) Record results on lab sheet( ) Report results to physician( ) Maintain urine for possible further lab testing( ) After patient discharge, dispose of urine in toilet and testing supplies into trash( ) Clean testing area as necessary with appropriate cleaning supply

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee signature: _____________________________________________

Trainer’s signature: ____________________________________________

Date of successful completion: ____________________________________


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6. Performing a Strep TestTesting for Group A Streptococci MAY be performed without a written order on any patient presenting with a complaint of sore throat with the following exceptions: 1. Patient under 24 months of age 2. Excessive drooling Informed consent is necessary – so patients should be given the option of seeing the Provider first. Although not an invasive procedure, since it involves obtaining a body fluid, universal precautions apply.

Performance Checklist( ) Gather necessary equipment to patient’s room (use only swabs contained in strep kits)( ) Explain testing procedure( ) Put on gloves( ) Have patient open mouth so that back of throat can be visualized( ) Depress the tongue using a tongue depressor( ) Rub the swab on back of the throat, tonsils or anywhere there is redness, inflammation or pus (DO NOT touch the swab to the tongue, sides or top of mouth)( ) Since individual manufacturer’s test kits vary, be sure to review the processing instructions prior to performing the test( ) Read results and record on patient chart( ) Dispose of all test equipment appropriately

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



Date of successful completion: _____________________________________


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7. Performing Pulse OximetryDefinition: Pulse oximetry measures oxygen saturation correlating with arterial blood gas levels if the patient does not have peripheral vascular disease.Pulse oximetry is generally ordered by the physician but can be obtained by a staff member if patient symptoms indicate. It should not replace or delay more definitive treatment or care if the patient is experiencing respiratory distress.

Performance Checklist( ) Confirm the written order (if appropriate)( ) Gather pulse oximetry device( ) Explain procedure to patient( ) Choose an appropriate site *see below*( ) Remove obstruction such as nail polish or synthetic nails( ) Check capillary refill at site( ) Apply sensor to site without allowing gaps( ) Allow sensor to remain on site for 1 full minute( ) Obtain SpO2 measurement and pulse( ) Record measurements on patient’s chart( ) Clean sensor (if necessary) and returnPossible sites include: fingers, toes, earlobes, and bridge of nose depending on style of sensor

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



Date of successful completion: ______________________


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8. Wound ManagementIt is the policy of Golden Gate Urgent Care that all open traumatic injuries are thoroughly scrubbed and irrigated as a part of overall wound care. Deviations from the protocol may only occur per the physician’s order.Performance Checklist( ) Assist patient to lie down on exam table with injured area exposed and accessible( ) Put on PPE appropriate to extensiveness of wound( ) Expose wound/dispose of any contaminated bandages( ) Assess history and vital signs( ) Check patient tetanus status – Update as needed( ) Prepare necessary equipment for suturing (laceration pack, suture material, fenestrated drape, sterile surgical gloves, other items as needed)( ) Set up suture tray with fenestrated drape( ) Set out appropriate size sterile surgical gloves( ) Draw appropriate medication for numbing (Lidocaine for local; Lidocaine or Marcaine for digit block; Lidocaine with Epinephrine for head wounds)( ) Have physician assess injury and anesthetize( ) Gather basin, irrigation gun, saline, Zerwet, antibacterial scrub( ) Connect irrigation gun to liter bag of Normal Saline and prime gun( ) Begin by gently scrubbing wound to remove debris( ) Irrigate the wound using the irrigation gun. Policy is to irrigate each wound using minimally 100cc of saline per centimeter of wound ( ) Dispose of used supplies into Biohazard( ) Apply iodine around wound edge( ) Inform physician that patient is ready to suture( ) Upon completion of suturing, clean wound around sutures( ) Apply dressing and bandage per physician instruction( ) Give patient wound care instruction sheet and go over verbally( ) Inform patient of recheck date

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Trainee’s signature: ____________________________________________

Date of successful completion: _________________________


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8.5 Wound Prep Post Test1. What items do you need to gather to clean a wound?

2. What solution is used for irrigating wounds?

3. What is the minimum amount of saline (ml) used to irrigate a wound?

4. What is the difference between a “fenestrated” and “non-fenestrated” drape?

5. What 4 items (minimally) are prepped for the practitioner?

6. What size and type of suture material is commonly used for simple, surface laceration?

7. What size and type of suture material is commonly used for a tendon laceration?

8. What type of suture material is commonly used for subcutaneous laceration repairs?

9. What type of suture material is commonly used for head/scalp lacerations?

10. What is a “Zerowet” and what is it used for?

11. How often is a “Zerowet” changed?

12. What is a “tournicot” and what is it used for?

13. Who is responsible for removing the tournicot?

14. How often are irrigation guns changed?

15. Once the wound is cleaned, what do you do next to prepare the wound?

16. What type of local anesthetic is used for wound repair?

17. When is “lido w/ epi” commonly used?


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9. Dispensing Medication from DRX System

The CLINIC policy states that all medications must be ordered by a physician or PA prior to dispensing. The physician or PA must authorize any changes involving the patient’s medication or any refill requests.

Also – All clinical staff members must first take a CLINIC pharmacology class and pass the post test prior to being trained on dispensing medications.

Hands on dispensing training is conducted by designated trainers within the clinic once proficiency with medication recognition has been demonstrated.

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee’s Signature: _______________________

Trainer’s Signature: ________________________

Date of Successful Completion: ________________


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10. Performing a Urine HCGCollection and testing of a urine pregnancy test (urineHCG) may be performed without the order of a physician. Patients may elect to have a urine pregnancy test without seeing the physician. However, the nursing staff member should counsel the patient to seek prenatal care if the test result is positive. Although not an invasive procedure, it involves obtaining body fluid.\ Universal precautions apply.

Performance Checklist( ) Gather necessary equipment to patient’s room (urine cup and HCG test kit)( ) Explain testing procedure( ) Direct patient to bathroom( ) Put on gloves( ) Take specimen from patient( ) Remind patient to wash hands( ) Take pipette, withdrawing urine from specimen cup( ) Place 3-4 drops of urine into the test reservoir( ) Remove gloves and wash hands( ) Wait 5 minutes and record results on lab sheet( ) Report results to patient( ) If positive – advise patient to seek prenatal care( ) After patient discharge, dispose of urine in toilet and testing supplies into trash( ) Clean testing area as necessary with appropriate cleaning supply

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



Date of successful completion: _____________________


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11. Performing a Mono Spot TestTesting for Mononucleosis should be performed with the order of a physician. Since the procedure involves obtaining a body fluid, universal precautions apply.

Performance Checklist( ) Confirm the written order( ) Gather necessary equipment to patient’s room (Mono test kit, lancet, alcohol prep)( ) Explain testing procedure( ) Put on gloves( ) Select finger (preferably not thumb or index)( ) Clean finger using alcohol prep( ) Using lancet, puncture finger( ) Dispose of lancet into sharps container( ) Gently squeeze finger and wipe away initial drop of blood( ) Insert black plunger into end of capillary tube with white lines( ) Touch open end of capillary tube to blood( ) Fill capillary tube to black line( ) Touch tip of capillary tube to sample well( ) Depress plunger to push blood onto sample well( ) Discard capillary tube into sharps container (Do not dispose black plunger – it is not contaminated since it never touches body fluid)( ) Add three drops of developer to sample well( ) Provide patient with gauze or Band-Aid( ) Read results between 6-8 minutes (Results are invalid after 15 minutes)( ) Read results and record on patient chart( ) Dispose of all test equipment appropriately

Comments: ________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________





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12. Administering Intradermal InjectionsIt is the policy of Golden Gate Urgent Care that all intradermal medications must be ordered by a physician and administered by a nursing staff member that has shown competency.

All medication orders must be verified according to the five rights prior to administration.

Intradermal injections are generally performed using a 27g. ½” needle attached to a tuberculin syringe.

***Most commonly administered intradermal injection is for Tb testing ***

Performance Checklist( ) Confirm the written order( ) Assembles the appropriate size needle and syringe according to the type of medication, size of patient, and volume of medication( ) Reads label 3 times to verify 5 Rights( ) Withdraws medication into syringe( ) Chooses the appropriate site (For testing, the site is generally the inner aspect of either forearm)( ) Put on gloves( ) Cleanses site with alcohol( ) Spreads skin taut with alcohol( ) Inserts needle (bevel up) nearly parallel to patient’s skin( ) Aspirates to check for blood( ) Injects medication if no blood is seen on aspiration( ) In the case of Tb testing, injections should produce a well-defined weal.( ) Removes the needle( ) Disposes of needle/ syringe appropriately( ) Removes gloves and washes hands( ) Records administrations on patient’s chart( ) Records administration in injectables log( ) Advises patient to have site re-evaluated in 48-72 hours specifically( ) Completes appropriate Tb paperwork

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee’s Signature: ____________________________

Trainer’s Signature: _____________________________

Date of Successful Completion: ____________________


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13. Instrument CleaningIt is the policy of Golden Gate Urgent Care that all medical instruments be cleaned and sterilized following use or compromising of sterility in the following outlined manner.

Any instrument that has been used or removed from sterile wrapping shall be considered contaminates and not for use in the treatment of any patient.

1. Put on gloves and protective eye wear.2. Gather instrument(s) into a puncture resistant container for transportation to cold sterilization bath (i.e., small metal container located on each trauma room)3. Prepare cold sterilization bath by adding 1 ounce of Metrizyme, EmPower or other accepted enzymatic cleaner to container and filling remainder with tap water. (The use of an enzymatic dictates that the solution be changed daily) 4. Place instruments into cold sterilization container.5. All instruments MUST soak for a minimum of 20 minutes.6. Remove instruments, scrub with assigned brushes, and rinse with tap water.7. Place instrument onto a clean towel and allow to completely air dry.8. Place instruments into individual sterilization pouches or wrap in blue sterilization paper.9. Place wrapped instrument into autoclave tray.10. Close and lock autoclave door.11. Turn autoclave on and select “wrapped” process.12. Autoclave will beep to alert staff to open door to vent (exercise caution when opening door as steam being vented is extremely hot)13. At the completion of the cooling cycle, the autoclave will beep to alert staff to shut the device off.

All instruments prepared and autoclaved should be dated for one (1) month in advance to alert staff that sterilization may be compromised past this date.

In addition: the staff member packaging or wrapping instruments should place their initials on the autoclave tape or top of pouch.

Successful sterilization has occurred when autoclave tape turns black or pouch markers turn brown.

Instruments that are stained can be successfully cleaned with the appropriate Miltex cleaner.

Any variations on this procedure or problems with sterilization must be reported to the clinical coordinator or nursing supervisor immediately.

Comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Trainer’s Signature: _______________________

Date of Successful Completion: _______________


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14. Instrument Identification Test

Name: ____________________ Date: ______________________

1. Name the instruments that should be included when packaging suture kits.

2. What two instruments make up a tissue kit?

3. What two instruments make up a suture removal kit?

4. How can you tell the difference between the Ronguers and the toenail nippers?

5. Put the following steps in the correct order:

1.______ a. place dry instruments in wrap or pouches

2.______ b. soak instruments in cleaning solution

3.______ c. place instruments in autoclave

4.______ d. scrub instruments with brushes

5.______ e. run autoclave

6.______ f. rinse instruments

7.______ g. air dry instruments

6. T/F You should sterilize disposable instruments

7. T/F Damaged Miltex instruments should be thrown away

8. T/F Enzymatic cleaners will remove all tissue and blood

9. T/F Instruments should be packaged closed so that they do not puncture envelopes.

10. T/F Splinter forceps have teeth

11. What is the shelf for unopened sterilized instruments? ______________________

12. How often should you change the enzymatic cleaner?

13. How can you tell if an instrument has been properly sterilized?

14. What is the minimum amount of time that instruments should soak in the enzymatic cleaner?


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15. What happens with the soak time if additional instruments are added to the cleaner?

16. How should dirty instruments be transferred to and from the enzymatic soak?

17. What PPE should be worn when changing enzymatic cleaner or cleaning instruments?

18. What needs to be written on the outside of all packaged instruments?

19. How often are autoclave spore checks completed?

20. Must all instruments be autoclaves prior to use?


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15. New Employee Training ChecklistList 2- Second Month

The following list of training times must be completed and singed off by a designated trainer within the first 60 days if full-time employment. Any deviation or delays should be noted below.

1. Performing Ear Irrigations2. Performing Eye Irrigations 3. Preparing for Slit Lamp Exam/ Eye Injury4. Administering Nebulizer Treatments5. Administering Intramuscular Injections6. Administering Subcutaneous Injections7. Performing 12-lead EKG8. Administering Oxygen9. Performing Blood Glucose Test (Accu-Check)10. Patient Call-Backs11. Scheduling MRIs12. Scheduling Other Tests (CT/Ultrasound/EMG/Specialty Physicians)13. PT referrals14. Scheduling Referrals

Comments:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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16. Performing an Ear IrrigationIt is the policy of Golden Gate Urgent Care that ear irrigations must be ordered by a physician and may only be performed by staff member that have demonstrated proficiency. Further, manual irrigation of ears using a syringe may only be performed by certified MA’s, LPNs, RNs, PA, or physicians.

( ) Confirm the written order( ) Gather the appropriate equipment ( ) Verify that patient has no medical condition that contraindicates using the ear wash system (i.e., Diabetes, ruptured TM, tubes in ears, patient age)( ) Collect water (warm to touch)( ) Cover patient with drape or provide blue chux to catch any excess water( ) Attach disposable ear tip (green tip) to syringe( ) Fill syringe with warm water( ) Insert ear tip into canal( ) Pull ear lobe gently backwards to help straighten canal( ) Depress plunger slowly ( ) Monitor patient and irrigation effort (check effectiveness of irrigation by observing if ear wax has accumulated in ear tip reservoir or if TM can be visualized)( ) Continue with irrigation until tympanic membrane can be visualized (It may be necessary to use a wax softening agent such as Debrox or sodium bicarb)( ) If patient complains of sudden onset of pain, extreme pain with procedure, water running into throat or nose – discontinue the procedure immediately and notify the physician( ) Upon completion, staff must document a post-procedural note on the patient’s chart( ) Dispose of ear tip

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Trainer signature: ______________________________________________



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17. Eye IrrigationIt is the policy of Golden Gate Urgent Care that all eye irrigation must be ordered by a physician and administered by a clinical staff member who has shown competency in this area.

Eye irrigation shall be performed using Morgan Lens equipment.( ) Put on gloves( ) Gather the equipment necessary for irrigation( ) Instill ophthalmic anesthetic into affected eye(s) ( ) Attach Morgan Lens tubing to 1 liter bag of Lactated Ringers Solution and flush air from tubing ( ) Have patient look down and insert lens under upper lid. Then have patient look up, retract lower lid and drop lens in place( ) Secure tubing to patient’s forehead to prevent accidental lens removal( ) Adjust flow by opening roller clamp on tubing. If performing bilateral irrigation, remember to unclamp second tubing( ) Flow should be maintained at a rate comfortable to the patient A fast rate is often painful( ) Check patient frequently to assure flow and comfort. Do not allow to run dry( ) At conclusion of irrigation, continue flow, have patient look up while gently removing lens( ) Dispose of tubing. Remove tray and bucket and dispose of excess solution( ) Provide towel to patient to dry hair or face( ) Watch video

Any discomfort not relieved by adjusting flow or the application of anesthetic drops should be immediately reported to the ordering physician and irrigation ceased.

Comments: ________________________________________________________________________

Trainee’s Signature: ______________________________

Trainer’s Signature: ______________________________

Date of Successful Completion: ______________________


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18. Preparing for a Slit Lamp Exam/ Eye InjuryIt is the policy of Golden Gate Urgent Care that all patient complaints involving the eye should have a visual acuity obtained prior to examination. Further, any eye injury involving a corneal defect should have patient’s tetanus status determined and updates as appropriate.

( ) Check patient in, obtaining chief complaint, history, vitals( ) Obtains visual acuity/ documents results (note if results are with corrective lenses)( ) Direct patient to exam room equipped with slit lamp. (room number varies by clinic)( ) Uncover and prepare slit lamp( ) Position slit lamp in front of patients carefully without jarring apparatus.( ) Place tissue near patient for use during exam( ) Gather “eye tray” checking that all necessary equipment is available( ) Place eye tray on top of chart-ready for physician( ) Physician may require assistance with holding patient’s eye open during exam. ( ) Following discharge of patient, recover slit lamp and restock eye tray as needed.

Comments:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee’s Signature: ________________________

Trainer’s Signature: _________________________

Date of Successful Completion: ________________


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19. Administering a Nebulizer TreatmentIt is the policy of Golden Gate Urgent Care that all medications must be ordered by a physician and administered by a nursing staff member that has shown competency. Since the administration of a nebulizer treatment involves the administration of an inhaled medication, it is covered by this policy.

All medication orders must be verified according to the 5 rights prior to administration.

Performance Checklist( ) Confirm the written order( ) Gather the nebulizer device with appropriate mouthpiece and appropriate medication( ) Perform pulse oximetry prior to beginning nebulizer (if ordered by physician)( ) Explain procedure to patient ( ) Assemble nebulizer tubing, mouthpiece (or face mask), and medication reservoir ( ) Connect tubing to machine( ) Fill reservoir with appropriate medication( ) Hand mouthpiece to patient (or assist with proper fitting of mask)( ) Turn Machine to “ON”( ) Briefly monitor patient’s efforts( ) Check patient at 5 minutes until medication is completely administered( ) Conduct post-nebulizer pulse oximetry if ordered( ) Administer another nebulizer treatment of ordered( ) Dispose of mouthpiece (or mask) and tubing( ) Inform physician of completed treatment

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee’s Signature: ______________________

Trainer’s Signature: ______________________ Date of Successful Completion: ________________


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20. Administering IM MedicationIt is the policy of Golden Gate Urgent Care that all IM medications must be ordered by a physician and administered by a nursing staff member that has shown competency.

All medication orders must be verified according to the 5 Rights prior to administration.

IM medication administration should be performed with no less than a 25 g 1” needle (for adults) attached to a locking syringe.

A volume of 3cc is considered the maximum amount to be given in one injection.

Refer to Injection Appendix for further information and guidelines.

Performance Checklist( ) Confirm the written order ( ) Assemble the appropriate size needles and syringe according to the type of medication, size of patient, and volume of medication.( ) Read label of medication at least three times to verify 5 Rights( ) Withdraw the medication into syringe( ) Put on gloves( ) Cleanses site with alcohol( ) Spreads skin over the site( ) Inserts needle quickly at a 90-degree angle( ) Aspirates to check for blood( ) Inject the medication if no blood is seen on aspiration( ) Remove the needle( ) Massage site and cover with bandage( ) Dispose of needle/ syringe appropriately( ) Remove gloves and wash hands( ) Record administration on patient’s chart( ) Record administration in injectables log( ) Reassess patient reaction to medication if appropriate

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee’s Signature: ________________________________Trainer’s Signature: ________________________________Date of Successful Completion: ______________________


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21. Administering Subcutaneous InjectionsIt is the policy of Golden Gate Urgent Care that all subcutaneous medications must be ordered by a physician and administered by a nursing staff member that has shown competency.

All medication orders must be verified according to the 5 rights prior to administration.

Subcutaneous injections are generally performed using a 25g. 1” needle attached to a locking syringe.

Refer to Injection Appendix for further information and guidelines.

Performance Checklist( ) Confirm the written order( ) Assemble the appropriate size needle and syringe according to the type of medication, size of patient, and volume of medication( ) Read label 3 times to verify 5 Rights( ) Withdraw medication into syringe( ) Put on gloves( ) Choose appropriate site( ) Cleanse site with alcohol( ) Bunch skin at site( ) Insert needle quickly at 45-degree angle to patient’s skin( ) Aspirates to check for blood( ) Inject medication if no blood is seen on aspiration( ) Remove the needle( ) Massage site and covers with bandage( ) Disposes of needle/syringe appropriately( ) Remove gloves and washes hands( ) Record administration on patient’s chart( ) Record administration in injectables log( ) Reassess patient reaction to medication of appropriate

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee’s Signature: ____________________________Trainer’s Signature: ____________________________Date of Successful Completion: ___________________


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22. Administering Allergy MedicationsIt is the policy of Golden Gate Urgent Care that all allergy medications must be ordered by a physician and administered by a nurse or staff member that has shown competency.

Further: All patients receiving scheduled injections should be monitored for a minimum of 15 minutes following injection for any adverse reactions.

Allergy injections are often administered subcutaneous—but ultimately are administered according to a table of scheduled injections set forth by the ordering physician

***Any questions regarding scheduled injections should ultimately be referred to the ordering physician***

Performance Checklist( ) Confirm the written order( ) Verify the scheduled injection( ) Assemble the appropriate size needle and syringe according to the type of medication, size of patient, and volume of medication( ) Read label 3 times to verify 5 Rights( ) Withdraw medication into syringe( ) Choose appropriate or directed site( ) Put on gloves( ) Cleanse site with alcohol( ) Administer medication as directed *Follow policy and procedure for appropriate method of administration*( ) Aspirates to check for blood( ) Inject medication if no blood is seen on aspiration( ) Remove the needle( ) Dispose of needle/syringe appropriately( ) Remove gloves and wash hands( ) Record administration on patient’s chart( ) Record administration in injection log( ) Monitor patient for 15 minutes( ) Re-examine injection site. Assess for reaction( ) Document absence or presence or reaction at site or systematically

***Any patient receiving allergy injections must be monitored for systemic allergic reactions such as shortness of breath, rashes, hives, chest pain or difficulty breathing.***Epinephrine (adrenalin) 1:1000 should be kept readily available for SQ injection in case of systemic reaction.

Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee’s Signature: _______________________________

Trainer’s Signature: ______________________________

Date of successful Completion: ______________________


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23. Obtaining 12-Lead EKG

It is the policy of Golden Gate Urgent Care that all patients with a complaint of chest pain or discomfort (or any other symptoms indicating a possible heart problem) shall have an immediate EKG.

A 12-Lead EKG may be obtained without the order of the physician if the nursing staff member feels it is appropriate. Performing the EKG should not delay more definitive care. The on-duty physician should be notified ASAP of any potential chest pain patient.

Performance Checklist( ) Confirm the written order on the patient’s chart( ) Patient should be in gown with opening in front (females remove bra)( ) Bring necessary equipment to room( ) Have patient lay as flat as possible and relax( ) Unite gown at top so that access to patient’s chest is possible( ) Remove excess hair (shaving), or moisture if necessary ( ) Attach “Blue Dot” electrodes to patient according to diagram on EKG machine( ) Attach leads to patient according to diagram on EKG machine( ) Depress the green button to turn machine on if it is not already on( ) Select Auto, then F1 to enter patient data, F2 will move to the next field, press F6 when done entering data( ) Instruct patient to lie still and breathe normally while EKG is running( ) Again hit the F6 button and you can then run a rhythm strip, when you have a full page of rhythm strip hit the stop key( ) Verify with physician that EKG is of adequate quality( ) When good EKG has been captured, unhook leads from patient and instruct them to pull off the electrodes and resume a comfortable position( ) Make a copy of both the EKG and rhythm strip( ) If you are having difficulty defer to the training manual for tips

It may be necessary to alter lead placement several times to obtain an adequate tracing. Check to be sure leads are making good contact with patient skin. If it is necessary to shave hair from chest REMEMBER that the razor is then considered a contaminated sharp and must be disposed of in the appropriate manner.

Comments:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee’s Signature: _________________________

Trainer’s Signature: __________________________

Date of Successful Completion: _______________________________


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24. Administering OxygenOxygen administration is usually ordered by a physician; however, any nursing staff member may initiate oxygen therapy if warranted by patient condition.

Oxygen administration is considered appropriate initial care for patients experiencing any respiratory difficulty, chest pain or significant trauma and should not be delayed in these conditions.

Performance Checklist( ) Confirm the written order (if appropriate) ( ) Gather the oxygen tank and appropriate delivery system (cannula or mask)( ) Wash hands( ) Assist patient to position of comfort or position appropriate for patient’s condition( ) Connect tubing or regulator( ) Open cylinder( ) Adjust flow of oxygen as ordered or as appropriate for patient’s condition( ) Apply oxygen delivery device to patient( ) Adjust fit of device for comfort and to avoid leakage( ) Observe patient’s immediate response( ) Document start of therapy, rate of flow, and delivery system( ) Reassess every 5 minutes to check patient condition and adequacy of flow( ) Consider pre-and post-oxygen administration pulse oximetry measurements( ) Record vital signs as ordered or as appropriate

Method of Delivery___________________________Usual Rate of FlowNasal cannula 4-6 liters per minute Not to exceed 6 (delivers 28-44% oxygen)Simple Mask 8-10 liters per minute (delivers 50-60% oxygen)Mask w/ Reservoir bag 10-15 liters per minute (delivers 90-100% oxygen)

Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee’s Signature: _____________________________________

Trainer’s Signature: _____________________________________

Date of Successful Completion: ____________________________


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25. Performing Blood Glucose TestIt is the policy of Golden Gate Urgent Care that blood glucose testing should be ordered by a physician

( ) Confirm the written order( ) Gather the testing equipment( ) Select finger—avoiding thumb or other calloused areas( ) Clean area with alcohol-allowing to air dry( ) Inserts test strip into monitor (Some models require unit to be “turned on” first)( ) While holding tension on skin, uses lancet to prick skin( ) Dispose of lancet into sharps container( ) Clean initial blood off with 2x2( ) Gently squeezes to express more blood( ) Apply sample to test strip—activating testing( ) Clean excess blood from finger—apply bandage( ) Record results from monitor( ) Dispose of test strip( ) Turn off monitor of appropriate( ) Inform physician of abnormal results

Test strips do expire and are specific to certain models. You must check that the correct test strip control number has been programmed into unit. You must also check that test strips have not expired.

Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee’s Signature: ___________________________

Trainer’s Signature: ____________________________

Date of Successful Completion: ___________________


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26. Handling Patient Call-BacksGolden Gate Urgent Care makes it our practice to call every patient seen in our facilities three days from their visit to check on their status and offer further treatment advice as needed. Clinical staff members will frequently be required to answer an incoming patient phone call. Patient’s most frequently call with questions about their condition or care. They might also be calling to inform us of a condition that is not improving or worsening. It is the policy of Golden Gate Urgent Care that medical advice must be obtained from the physician or PA on duty. Unlicensed staff members should not give out medical advice beyond the scope of their practice. Every communication with a patient must be documented in the patient’s chart. When making daily patient call-backs, any information obtained beyond “status improving” should be recorded on a patient call- back formed (attached).

The following are guidelines for handling patient call-backs:1. Call backs should not be started before 9 am. 2. Always use a professional, courteous tone during communication.3. Always address the patient by proper name.4. Always identify yourself and Golden Gate Urgent Care, stating that this is a “courtesy call to check on the

patient”. This prevents patients from treating our call like any telemarketing call.5. When completing a call-back on a patient who is a minor - ask for a parent or guardian. 6. Leave a brief message whenever possible.7. Document patient complaint or request. When handling refill requests- ask and document pharmacy

preference.8. Patients complaining of possible medication reactions or worsening conditions involving shortness of breath,

chest discomforts, excessive pain in fractures, etc., should be brought to the physician’s or PA’s attention immediately.

9. Never identify yourself as the “nurse” unless you possess an actual nursing license.10. Always remind and encourage patients to keep their recheck appointments.11. Any complaints of services or treatment that cannot be immediately resolved should be initially referred to

the Clinic Coordinator.

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________





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27. Scheduling Tests (CT/US/Specialist)Clinical staff members will frequently be required to make referrals for our patients to other physicians or to schedule testing outside our facilities. A physician always orders these referrals with specific instruction to which physician or facility the patient should be scheduled with.In addition, many of our corporate clients have specific preferences as to the physicians or facilities they will use for referrals or testing. You must refer to the list located in the front of the referral book. Also, prior to scheduling a referral of any sort for a Worker’s Compensation patient, you must first check the “pre-authorization required” list to determine if the Worker’s Compensation carrier must be contacted for approval prior to scheduling.1. Locate the General referral form in the referral book (samples of these forms are located in appendix of training manual)2. Complete the patient information section. 3. Complete the patient question section, also asking if the patient has any preference for appointment date/time.4. Call facility to schedule appointment. 5. Notify physician of appointment date and time.6. Arrange for necessary copies of chart/ x-rays / or reports to accompany patient.7. Notify patient of appointment date and time.8. Copy form- originals stay with chart, patient receives one copy, second copy placed in referral file/9. Document referral/ test in patient’s chart10. Provide patient with instructions and directions as needed.

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________





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28. Physical Therapy ReferralsReferrals for physical therapy are ordered by the physician or physician assistant and are generally scheduled in-house. In general, initial therapy appointments should be scheduled no later than 3 days from current visit. Any deviations should be documented.

( ) Notes order for therapy – located in lower left of RTW or written in treatment plan of private chart( ) Calls physical therapy department of appropriate PT facility( ) Provides patient information and current diagnosis( ) Documents first appointment date, time, and location on RTW or superbill( ) Informs patient of appointment and provides directions to facility( ) Faxes copy of RTW or superbill to proper physical therapy location

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________





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29. Orthopedic Referrals Clinical staff members will frequently be required to make referrals for our patients to other physicians or to schedule testing outside our facilities. A physician orders these referrals with specific instructions to the appropriate physician or facility.

In addition, many of the corporate clients have specific preferences as to the physicians or facilities they will use for referrals or testing. You must refer to the list located in the front of the referral book.

Also, prior to scheduling a referral of any sort for a Worker’s Compensation patient, you must first check the “pre-authorization required” list to determine if the Worker’s Compensation carrier must be contacted for approval prior to scheduling. 1. Locate the ortho referral form in the referral book (samples of these forms are located in appendix of

training manual).2. Complete the patient information section. 3. Complete the patient question section, also asking if the patient has any preference for appointment date/

time.4. Call _________________ to schedule appointment.5. Notify physician of appointment date and time.6. Notify patient of appointment date and time.7. Copy form- originals stay with chart; patient receives one copy, second copy placed in referral file.8. Document referral/ test in patient’s chart.9. Provide patient with instructions and directions as needed, including epidural information pamphlet.10. Send patient’s chart, including recent MRI reports to _______________ (cannot see the patient w/o the

chart, failure to send chart will result in delays in patient care).

Comments: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________





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30. New Employee Training ChecklistList 3 – Third Month

The following list of training items must be completed and signed off by a designated trainer within the first 90 days of full-time employment. Any deviations or delays should be noted below.

1. Reading Tb Test Result2. Obtaining Blood for Lab Testing (phlebotomy)3. Preparing for Casting/ Splinting4. Preparing for Joint or Soft Tissue Injections5. Preparing for I & D (incision and drainage)6. Preparing for Pelvic Exam w/ related testing7. Daily Chart Checks8. Attain EBT Certification9. Attain NIDA Certification10. Attendance in IV classes (optional)

Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________





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31. Reading Tb Test ResultsIt is the policy of Golden Gate Urgent Care to follow the guidelines established by the CDC when handling positive tuberculosis test results. All suspect indurations should be confirmed by the physicians or PA on duty.

( ) Retrieve patient’s Tb paperwork from the pending folder( ) Check site of injection for induration or reaction-( ) If an induration is noted or suspected, measure the induration in millimeters ( ) Follow the guidelines as set forth by the CDC in determining whether induration is considered positive Positive reactions are determined by the size of the induration and the type of employment and/or health status of the person. In general, the induration must be 15 mm or larger to be considered positive for a healthcare worker with no health concerns. Refer to posted guidelines.

( ) Document the induration as negative/ no induration or positive with induration listed in millimeters( ) If positive, patient should be evaluated by the physician and a 1 view chest x-ray ordered( ) The physician should document the x-ray results on the Tb form( ) Complete a referral form for the tuberculosis care center ( ) Give patient copies of the referral form, x-ray copies of Tb form( ) Document result in Tb log.( ) Send appropriate copies to medical records

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________





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32. Obtaining Blood for Lab TestingIt is the policy of Golden Gate Urgent Care that all blood draws will be performed by nursing staff that have shown competency and have been signed off on their training form.

All blood draws are to be ordered by the physician as to what specific lab testing should be performed.

All patients having blood drawn must be lying on an exam table to prevent any possible injury.

A maximum of two attempts can be made by any one nursing staff member.

Performance Checklist( ) Confirm the written order( ) Check lab reference manual to determine the amount of blood required and type of tube for transport (verify appropriate lab for specimen to be sent to)( ) Gather the appropriate tubes, tourniquet, vacutainer holder and needle( ) Prepare equipment (i.e.,-connects needle to needle holder, lies out tubes)( ) Explain the procedure to the patient( ) Wash Hands ( ) Have patient lie down or semi-recline( ) Inspect patient’s arm for site selection( ) Apply tourniquet ( ) Dons clean gloves( ) Clean site with aspect technique( ) Stabilize vein( ) Insert needle into vein( ) Insert tube into vacuum holder, depressing onto needle( ) Fill appropriate tube(s)( ) Release tourniquet( ) Withdraw needle and dispose correctly( ) Apply pressure over site( ) Applies dressing over puncture site( ) Remove gloves( ) Finish preparing collected blood as appropriate( ) Return or dispose of supplies( ) Complete lab requisition form and package specimen for pickup( ) Watch video on venipuncture

Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee’s Signature: ______________________


Date of Successful Completion: _______________


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Anticoagulants

When collecting blood for ordered lab work, it is important that correct transport tube is selected for collection. Always refer to the specimen collection handbook for the appropriate laboratory to determine the correct collection method. Failure to collect the specimen as directed may delay results or invalidate the test.

The following is a brief description of anticoagulants added to transport tubes.

1. EDTA (Ethylenediaminatetraacetate) (Lavender top) –EDTA is used because it preserves the size and shape of cells. It prevents clumping of platelets. It is not used for tests that measure electrolytes. Commonly used for CBC.2. Potassium EDTA (Tan top)-similar to above but has added potassium and the tubes are certified not to contain any amounts of lead.Commonly used for lead levels.3. Oxalates (Gray top) - seed because it does not cause significant shrinkage or enlargement of red blood cells. Commonly used for blood Glucose measurements.4. Citrates - a. Sodium Citrate (Blue top)—This additive is specific for coagulation studies. Commonly PT or APTT. b. Acid-Citrate-Dextrose (ACD) (yellow top)—The ACD mixture preserves red blood cells better than other additives. Commonly used for blood typing and Rh determination.

5. Heparin (Green top)-Preserves cells for morphology studies. Commonly used for hemoglobin and hematocrit level, and sedimentation rates.

6. *** Serum Separator (Tiger top) Tube has gel and clot activator.*** These tubes do not contain any anticoagulants- blood WILL clot and coagulate once collected in these tubes. Generally, once collected, the blood will be spun in a centrifuge causing the red blood cells to separate from the serum. This tube is commonly used for Chem-screens and electrolyte studies. Also commonly used for thyroid, prostrate, and liver profiles.


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33. Preparing for Casting or SplintingIt is the policy of Golden Gate Urgent Care that the physician or PA must perform all splinting or casting of fractures. Clinical staff members should be prepared to assist with application.

( ) The physician or PA should direct the staff member as to what type and quantity of material is required (e.g., 3x12, 4x15, 2”, 3” tape, etc.)( ) Gather the appropriate materials( ) Measure and apply the correct length of stockinet (if required) Stockinet should extend to a joint above and a joint below the fracture/injury site( ) Lay out correct splinting or casting material (including cast padding if necessary)( ) Fill sink with water (warm to hot water will cause casting material to harden too fast)( ) Prepare gloves for physician and assistant for casting( ) Notify physician that patient is ready( ) Hold appendage as directed by physician during splinting or casting( ) Upon completion, instruct patient on cast/splint care and global fracture charges( ) Clean up unused materials, dispose of waste material( ) Apply appropriate codes to patient’s chart-places correct “global period” form

Comments:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee’s Signature: __________________________

Trainer’s Signature: __________________________

Date of Successful Completion: __________________


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Splint / Cast Prep Post Test

1. Does CLINIC use plaster or fiberglass casting materials?

2. Who can apply casts?

3. Name 3 items necessary for casting?

4. How do you measure stockinette?

5. What is different about waterproof casting materials?

6. What supplies and quantities might you anticipate for an adult short arm cast?

7. What supplies and quantities might you anticipate for an adult short leg cast?

8. How long does it take for a cast to be completely hardened?

9. What are the 3 available sizes for “quick splints”?

10. How are “quick splints” held in place?

11. What information must be given to the patient following cast application?

12. What does the “90-day Global” mean?

13. Does every fracture require a cast for stabilization?

14. On average, how long does it take for a fracture to heal?

Bonus: What type of injury should not have the splint removed at all until completely healed?


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34. Preparing for Joint or Soft Tissue InjectionsIt is the policy of Golden Gate Urgent Care that all joint or soft tissue injections are to be administered by the licensed physician assistant on staff.

Clinical Staff that are preparing medications for administration should always follow the “5 rights” of medication.

( ) Confirm the written order( ) Gather the appropriate size needle and syringe according to the medication being drawn( ) Read labels at least three times to verify 5 Rights( ) Withdraw the appropriate amount and type of medication for administration (Always drawing steroid before Lidocaine)( ) Record information in injectables log( ) Attach the appropriate size needle for injection (Usually 27g 1 ¼” for larger joints)( ) Place syringe on tray with bottles of medication, alcohol prep, and Band -Aid( ) Prep area of injection (usually designated by physician) with iodine( ) Inform physician that patient and injections are prepared( ) Place appropriate codes on patient’s superbill

Comments:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



Date of Successful Completion: _____________


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35. Preparing for I&D’s (Incision and Drainage)Clinical staff members will frequently be asked to prepare a patient for the management of a cyst, abscess, paronychia or other condition requiring incision and/or drainage. The physician or PA will perform the actual procedure.

( ) The physician or PA should direct the staff member as to what type and quantity of material is required. (e.g., Lidocaine, packing gauze, necessary instruments, type of scalpel, syringes, needles)( ) Gather the appropriate materials( ) Place equipment and materials on mayo stand. It is usually easiest to open either a suture kit or package of sterile 4x4’s to create a clean area for materials and instruments( ) Prepare light source as necessary—for more involved procedures- consider moving patient to a trauma room( ) Prep area with iodine as directed( ) Prepare appropriate gloves for physician( ) Place patient in appropriate position( ) Notify physician that patient is ready( ) Assist physician as required( ) Package and complete requisition for any lab testing required( ) Clean and bandage area following procedure( ) Provide patient with wound care instructions( ) Clean and dispose of any trash appropriately( ) Place instruments in enzymatic cleanerComments:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Trainee’s Signature: ____________________

Trainer’s Signature: ____________________

Date of Successful Completion: ___________


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36. Preparing for a Pelvic ExamIt is the policy of Golden Gate Urgent Care that all pelvic exams conducted by a physician or PA will have another female staff member present during the course of the exam.

( ) Provide patient a gown and drape, instructing them to remove outer clothing and underclothing( ) Prepare Papanicolaou Smear equipment (if required)( ) Prepare KOH and Saline slides (if required)( ) Prepare GC/Chlamydia swabs (if required)( ) Attach light source to speculum( ) Prepare K-Y jelly( ) Provide gloves for physician and staff assistant ( ) Open large Biohazard receptacle for disposal of speculum( ) Inform physician that patient is prepared( ) Assist patient to exam position—covering with drape( ) Adjust stirrups for patient( ) Assist physician with sample collection for testing( ) Assist patient to sit up upon completion( ) Complete packaging and requisition of any samples for testing( ) Clean up exam room after patient discharge—disposing of speculum or any swabs used in the exam in the biohazard receptacle( ) Put away speculum light source

Comments:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee’s Signature: _____________________

Trainer’s Signature: ______________________

Date of Successful Completion: ______________


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37. Completing Daily Chart ChecksIt is the policy of Golden Gate Urgent Care that all charts will be checked on a daily basis to detect and correct errors.

The other goal of chart checks is to detect error trends that staff may be doing in an effort to correct these trends. The following are guidelines for completing daily chart checks:

Gather all charts (pvt and W/C) from the day. Charts should be checked frequently throughout the day to avoid leaving a large number for closing time. Furthermore, frequent checks of W/C charts should be made to assure that the physician has dictated on the chart and all comp calls have been made prior to the physician leaving.

1. Check that the physician/ PA has signed the chart.2. Check for missing time-out and nursing initials on discharge instructions.3. Check for nursing initials on procedures. Injections, medications dispensed.4. Check that all injections list a location and time given.5. Audit for errors according to protocol (e.g., Complete vitals, review of systems, history, tetanus status).6. Audit for recheck appointments, referrals, pending labs.7. Check that chart has all necessary charges (E&M, procedures, medications, injections, tests, supplies).8. Check that all appropriate CPT codes and modifiers have been listed.9. Check that a diagnosis and diagnosis code(s) have been listed.10. Check that all correct HCPCS codes for supplies have been listed.11. Audit global charges – place 10 day or 90 global form if not already done.

If any charging or coding errors are found- make a copy with the correction highlighted and send to billing.

Excessive errors committed by a single staff member should be brought to the Clinic Coordinator’s attention.

Upon completion of chart audit- file private charts alphabetically for call-back in 3 days. All W/C charts should be placed in a large folder with the dictation tape in the designated area for transcription.

Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________





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38. Clinical Opening ProceduresThe following duties are to be completed daily at each facility. Deviations or problems should be reported to the Clinical Coordinator.

1. Morning Narcotic Count2. Clinitek calibration3. Check pending Tb file4. Print available labs from computer5. Pull callbacks6. Clean, package, and sterilize instruments7. Complete laundry8. Check and record refrigerator/ freezer temperatures9. Check thermostats for proper settings


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39. Clinical Closing Procedure1. Wipe down all counters in the nursing area and trauma with proper cleansing solution.2. Verify what all patient calls have been addressed and that calls have been returned.3. Turn off otoscope / opthalascope bases.4. Turn off UA machine.5. Turn off PFT machine and printer.6. Lock all cabinets and drawers containing sharps.7. Clean, package, and sterilize instruments.*** Do not run autoclave if no staff member is present to monitor ***8. Check charts for documentation, coding and charging errors.9. Document private rechecks, scheduling procedures, and referrals.10. Attempt all Worker’s Compensation recheck calls.11. Complete laundry.** Do not run washer and dryer if not staff member is present to monitor ***12. Complete evening narcotic count.*** All discrepancies must be corrected prior to leaving clinic. If unable to correct, the clinical coordinator must be notified ***13. Check thermostats for proper settings.14. Confirm out doors are locked and “open” sign is shut off.15. Confirm all lighting is shut off.16. Last staff member to leave must activate alarm system.


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40. Down-Time ProceduresThe following is a brief list of activities during down time. This list is not comprehensive Staff members should continually seek items that enhance clinical appearance or function.

1. Stock rooms, supply cabinets, trauma2. Clean, package, sterilize instruments3. Wipe down walls, baseboards, exam tables, counters4. Complete laundry5. Separate CCF’s6. Check and change sharp containers7. Chart audits8. Stock eye tray, toenail tray, ENT tray9. Check medications for expiration dates10. Sample medication audit11. Complete patient satisfaction surveys12. Assist other departments as needed13. Other tasks as assigned


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41. Intravenous InfusionIt is the policy of Golden Gate Urgent Care that all IV’s will be started by nursing staff that have shown competency and have been signed off on their training form.

All IV’s are to be ordered by the physician and must be monitored every 5 minutes after infusion begins.

Golden Gate Urgent Care requires yearly refresher of IV skills

Performance Checklist:( ) Confirm the written order( ) Gather the appropriate solution, tubing, venipuncture equipment, and IV pole( ) Explain the procedure to the patient( ) Wash hands( ) Tighten roller clamp on IV bag( ) Connect tubing to IV solution bag( ) Partially fill drip chamber( ) Open clamp and flush air from tubing ( ) Hang IV bag on pole( ) Have patient lie down or semi-recline( ) Prepare tape for securing IV line and prepares dressing material for cover( ) Inspects patient’s arm for site location( ) Chooses appropriate site for type and rate of administration( ) Place blue chux under arm to absorb blood, prevent spill( ) Apply tourniquet ( ) Dons clean gloves( ) Clean site with aseptic technique( ) Stabilize vein( ) Insert catheter and advance into vein( ) Observe for flashback and advance catheter( ) Compress skin over top of device to reduce backflow( ) Connect tubing without contamination or dislodging catheter( ) Release tourniquet( ) Open roller clamp to allow slow infusion( ) Note that drip continues and site does not become swollen( ) Apply dressing over puncture site( ) Secure catheter (hub connection) and tubing to patient with tape( ) Clean around site if necessary( ) Remove gloves( ) Adjust rate of flow( ) Return or dispose of supplies( ) Document on chart: time, type of fluid, rate of infusion, size of catheter used, and location of placement( ) Monitor IV site and flow every 5 minutes until completion( ) Continue to assess patient response

Comments:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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Trainer’s Signature: ___________________________

Date of Successful Completion: __________________


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42. Administering IV MedicationsIt is the policy of Golden Gate Urgent Care that all IV medications must be ordered by a physician and administered by a nursing staff member that has shown competency both with IV start and maintenance as well as medication administration.

Due to the fast onset of action of IV administered medications, all medications ordered will be checked for the 5 Rights prior to administration. It is advisable that a second nursing staff member double checks the medication for accuracy as well.

Performance Checklist( ) Confirm the written order ( ) Obtain IV access (as per IV Policy and Procedure)( ) Draw medication into syringe( ) Attach needle (20g. min.)( ) Wash hands( ) Locate injection port closest to site of insertion( ) Clean the injection port with alcohol swab( ) Insert the needle into port ( ) Pinch the tubing above the port (may also close roller clamp)( ) Aspirate to assess for blood return( ) Depress plunger of syringe instilling medication slowly over the recommended period of time( ) Release tubing (opens roller clamp) to permit IV solution to infuse( ) Remove needle from port( ) Dispose of needle into Sharps container( ) Verify that IV infusion continues at prescribed rate and remains patent( ) Wash hands( ) Document medication administration( ) Reassess patient reaction to medication

Comments:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trainee’s Signature: ____________________________




Page 1 - 56

Write a brief but specific description of where the following items are located

1. ace wraps

2. extra EBT mouthpieces

3. steristrips

4. 60 cc syringes

5. betadine (iodine) swab sticks

6. K-Y jelly

7. medi-rip

8. stack splints

9. hydrogen peroxide

10. razors

11. silver nitrate sticks

12. toe nail tray

13. adaptic or Xerform 2x3

14. arm slings

15. cautery units

16. viscous lidocaine

17. nebulizer equipment

18. sterile urine cups

19. Histofreeze w/ buds

20. iodophor packing gauze


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21. moudose saline

22. extra suture material

23. equalizer boots

24. rib belts

25. extra finger splints/ digit tip protectors

26. future wrist splints

27. stretcher sheets

28. blue booties

29. vaginal speculums

30. rectal speculums

31. butterfly needles

32. benzalkonium wipes

33. whirlpool

34. eye patches

35. nasal packing

36. nervepace equipment

37. extra irrigation guns

38. extra boxes of gloves

39. bulk 4x4

40. 3x12 splints

41. cast padding


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42. patellar knee support

43. elbow sleeve

44. elbow/heel pad

45. ice packs

46. ortho shoes

47. stirrup ankle support

48. tennis elbow support

49. lab testing swabs

50. hemocult developer and cards


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INJECTIONS AND VACCINES

Routes:Sub q Subcutaneous = Outer Aspect of Upper ArmIM Intramuscular = Administer in deltoid, dorsogluteal, ventrogluteal, or Vastus Lateralis muscle.Deep IM Deep Intramuscular = Administer in dorsogluteal muscle in AdultsIntradermal Intradermal = Administer between layers of dermis, generally in forearms

If you are unsure of how to administer any of these routes (i.e., pediatric routes), please contact a clinic coordinator.

Medication Route Needle SizeAllergy Injection Sub q 27g 1/2”Adrenalin Sub q 27g 1/2”Benadryl Deep IM 25g 1”-1 1/2” Dependant on pt sizeCelestone IM (or joint-administered

only by physician)25g 1”-1 1/2” Dependant on pt size

Chicken Pox Vaccine Sub q 27g 1/2”Compazine Deep IM 25g 1”-1 1/2” Dependant on pt sizeDepoMedrol IM 25g 1”-1 1/2” Dependant on pt sizeDHE 45 Sub q 27g 1/2”DT IM 25g 1”-1 1/2” Dependant on pt sizeDPT IM 25g to 27g Infants must be given this

injection in Ventrogluteal or Vastus LateralisHepatitis A IM Pre-filled SyringeHepatitis B IM 25g or 27gHepatitis Immune Globulin Deep IM 25g 1”-1 1/2” Dependant on pt sizeHaemophilus Influenza (HIB) IM (Ventrogluteal or Vastus

Lateralis)25g or 27g 1”

Influenza Vaccine IM 25g 1”Lyme Vaccine IM 25g 1”Kenalog IM Joint administered by

Physician25g 1”


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Changing for Radiographic Exams

Radiographic Exam Changing InstructionsAbdomen necklaces, bras, shirts, pants, belly rings (if able)AC Joints necklaces, bras, and shirtsAnkle socks, shoes, and ankle braceletsCalcaneous socks, shoes, and ankle braceletsChest shirt, bra, necklaces, and nipple rings (if able)Clavicle shirt, bra, and necklacesElbow shirt (if can’t be pushed up)Facial Bones earrings, necklaces, dentures, eyeglassesFemur pants/shortsFinger rings, watches, and braceletsFoot socks, shoes, and ankle braceletsForearm watch, bracelets, and shirt (if can’t be pushed up)Hand rings, watch, and braceletsHip pants/shorts, and belly rings (if able)Humerus shirt and braKnee pantsMandible earrings, necklaces, dentures, eyeglassesMastoids earrings, necklaces, dentures, eyeglassesNasal Bones earrings, necklaces, dentures, eyeglassesOrbits earrings, necklaces, dentures, eyeglassesPelvis pants/shorts, and belly rings (if able)Ribs shirt, pants/shorts, bra, necklaces, and nipple rings (if able)Sacroiliac Joint pants and belly rings (if able)Scapula shirt, bra, and necklacesShoulder shirt, bra, and necklacesSinuses earrings, necklaces, dentures, eyeglassesSkull earrings, necklaces, dentures, eyeglassesSpine, Cervical earrings, necklaces, dentures, eyeglassesSpine, Lumbar shirts, pants/shorts, bra, belly rings (if able)Spine, Thoracic shirt, bra, necklaces, and nipple rings (if able)Spine, Sacrum/Coccyx pants/shorts, shoes, socks, and ankle braceletsSternum shirt, bra, and necklacesTMJ earrings, necklaces, dentures, eyeglassesTibia/Fibia pants/shorts, shoes, socks, and ankle braceletsToe socks, shoes, and ankle braceletsWrist rings, watch, and bracelets


Page 1 - 61

Training Log Sign Off for Employee

Employee Name: Position: Date of Hire:

Training Date Completed Employee Initials

Supervisor’s Initials

Chart Documentation

Obtaining Vital Signs

Obtaining Orthostatic Vital Signs

Collecting Non-NIDA Drug Screens

Performing Alco-Sensor Testing

Performing Audio Testing

Performing Vision Testing

Performing Pulmonary Function Testing (PFT)

Nerve Conduction Testing

Nerve Conduction (NCS) Post Test

Performing a Dipstick Urinalysis with Clinitek

Performing a Strep Test

Performing Pulse Oximetry

Wound Management

Wound Prep Post Test

Dispensing Medication From DRX System

Performing a Urine HCG

Performing a Mono Spot Test

Administering Intradermal Injections

Instrument Cleaning

Instrument Identification Test

Administering Intradermal Injections

Instrument Cleaning

Instrument Identification Test

New Employee Training Checklist


Page 1 - 62

Performing an Ear Irrigation

Eye Irrigation

Preparing for a Slit Lamp Exam / Eye Injury

Administering a Nebulizer Treatment

Administering IM Medication

Administering Subcutaneous Injections

Administering Allergy Medications

Obtaining 12-Lead EKG

Administering Oxygen

Performing Blood Glucose Test

Handling Patient Call-Backs

Scheduling MRIs

Scheduling Other Tests

Physical Therapy Referrals

Epidural Referrals

Orthopedic Referrals

Reading TB Test Results

Obtaining Blood for Lab Testing

Preparing for Casting or Splinting

Preparing for Joint or Soft Tissue Injections

Preparing for Incision and Drainage

Preparing for a Pelvic Exam

Completing Daily Chart Checks

Clinical Opening Procedures

Clinical Closing Procedures

Down-Time Procedures

Intravenous Infusion

Administering IV Medications

Prevention

Patient Flow Goal: To provide every patient quality care within one hour of presenting to the clinic. Fast track (patients who see nursing staff only: To provide quality service within 15 minutes of presenting to the clinic.

Priorities QV Function Order x-rays prior to

physician seeing patient

Trauma patient

Keep Physician/PA Busy with charts

Assign staff to tasks/patients to

ensure that patient flow is moving

efficiently

Monitor charts in piles to ensure Fast Tracks are not lost in pending charts, x-rays done that should be,

scheduling completed

Monitor wait times

Check out patient

Fast track patients

Testing/Check in

Phone calls from patients, call backs

Nurses approved to order any extremity x-rays (including wrist & ankle) x-rays for

injuries

If unsure x-ray is needed (or not an extremity), must not place in pile, but present to

physician immediately to determine if x-ray is needed

After x-ray, place chart for Physician/PA

in time order

Copyright©2012. NMN Consultants. All rights reserved NMN Consultants. No part of this document may be produced in any form without the written consent of NMN Consultants.

Patient Flow

Problems

Evaluate wait times. Identify # of patients, type of patients, and # of patients still needing to be checked in by reception. Determine if present staff can work through

backlog through triage. If not, determine what type of staff is needed

Nursing staff needed

Contact Clinic Coordinator

Contact Director of

Nursing

Physician/PA needed

Contact PA on call

Contact Director of

Nursing

Backup due to room

shortage

Triage patients waiting using audio room/hallway/nurse’s

station

Obtain vitals, chief complaint, work up all P2’s (i.e., vitals, vision, audio, drug screen)

Use doctor’s office for simple W/C rechecks, if

doctor will allow

Contact Director of

Nursing if still having problems

Do not use rooms as “storage

sites” for patients drinking water to provide a drug screen

Have patients waiting for

meds/QV have a seat in the chair by checkout counter


www.health.state.mn.us/immunize (5/2011) IC# 141-2380

How to Administer IM (Intramuscular) Injections Administer DTaP, DT, Td, Tdap, Hib, hepA, hepB, HPV, TIV, MCV, PCV, and rabies vaccines via IM (intramuscular) route.

Administer IPV and PPSV vaccines either via IM or SQ (subcutaneous) route.

Patient’s age Site (see illustrations) Needle size* IM site for infants and toddlers (birth to 3 years of age)

Newborn/infant (Birth -1 year)

• Anterolateral thigh • 1" needle • 5/8" in premies or newborns

(0-28 days old) if muscle mass inadequate¹

• 23-25 gauge needle Toddler (1-3 years)

Children (3-11 years)

Adolescents/adults² (11 years and older)

• Anterolateral thigh preferred • Deltoid when adequate mass

developed • Deltoid • Anterolateral thigh • Deltoid preferred • Anterolateral thigh may be

used if necessary

• 1" – 1¼" needle for thigh • 5/8" – 1" needle for deltoid • 23-25 gauge needle • 5/8" – 1" needle for deltoid • 1" – 1¼" needle for thigh • 23-25 gauge needle • 1" – 1½" needle² • 23-25 gauge needle

vastus lateralis (shaded area) IM injection site area

¹ A ⅝” needle may be used only if the skin is stretched tight, the subcutaneous tissue is not bunched,

and injection is made at a 90° angle. ² A ⅝” needle is sufficient in adults weighing less than 130 lbs (60 kg).

A 1” needle is sufficient in adults weighing 130–152 lbs (60–70 kg). A 1–1½” needle is recommended in women weighing 152–200 lbs (70–90 kg) and men weighing 152–260 lbs (70–118 kg). A 1½” needle is recommended in women weighing more than 200 lbs (90 kg) or men weighing more than 260 lbs (118 kg).

Needle insertion • Use a needle long enough to reach deep into

the muscle. • Insert needle at a 90º angle to the skin with a

quick thrust.

Insert needle at 90º angle into vastus lateralis muscle in anterolateral aspect of middle or upper thigh.

IM site for older toddlers, children, adolescents, and adults

acromion

deltoid muscle (shaded area)

• Retain pressure on skin around injection site with thumb and index finger while needle is inserted.

skin

90º angle

IM injection site area

• Aspiration before injection is not required.*

• Multiple injections given in the same extremity should be separated as far as possible (preferably at least 1” apart).

subcutaneous tissue muscle

elbow

*Red Book 2009, American Academy of Pediatrics (p.19) and CDC General Recommendations on Immunization, 2011

Insert needle at 90º angle into densest portion of deltoid muscle above armpit and below acromion.

http://www.health.state.mn.us/immunize

www.health.state.mn.us/immunize (5/2011) IC# 141-2380

How to Administer SQ (Subcutaneous) Injections Administer MMR, MMRV, MPSV, VAR, and ZOS via SQ (subcutaneous) route.

Administer IPV and PPSV vaccines either via IM (intramuscular) or SQ route.

Patient’s age Site (see illustrations) Needle size* SQ site for infants and toddlers (birth to 3 years of age) Infants (Birth -1 year)

• Fatty area of the thigh • 5/8” needle • 23-25 gauge

Toddlers (1-3 years)

• Fatty area of the thigh or outer aspect of upper arm

• 5/8” needle • 23-25 gauge

Children (3 -11 years)

• Fatty area of the thigh or outer aspect of upper arm

• 5/8” needle • 23-25 gauge

SQ injections site area

Adolescents/adults (11 years and older)

• Outer aspect of upper arm • 5/8” needle • 23-25 gauge

Needle insertion • Insert needle at an 45º angle to the

skin. • Pinch up on SQ tissue to prevent

injecting into muscle. • Aspiration before injection is not

required.*

45º angle

Insert needle at 45º angle into fatty area of anterolateral thigh. Make sure you pinch up on SQ tissue to prevent injecting into muscle.

SQ site for older toddlers, children, adolescents and adults

acromion • Multiple injections given in the same

extremity should be separated as far as possible (preferably at least 1” apart).

skin subcutaneous tissue

SQ injections site area

muscle

*Red Book 2009, American Academy of Pediatrics (p.19) and CDC General Recommendations on Immunization, 2011

elbow

Insert needle at 45º angle into outer aspect of upper arm.

Make sure you pinch up on SQ tissue to prevent injecting into muscle.

http://www.health.state.mn.us/immunize

Fire Safety Training



Fire Alarm • A fire alarm means EVACUATE • Exit the nearest safe exit • Close doors to confine the fire • Gather at one of the “assembly points” in order to facilitate an

accurate head count. • Assembly points are located in the front and back of the

building. • DO NOT return to the building until the “all clear”

announcement is made.


Emergency Evacuation Floor plans • Emergency Evacuation Floor plans are posted in

different areas of the building • It is important that you familiarize yourself with the

evacuation plans for you area and well as other areas throughout the building.


Exits & Fire Doors • In a fire, they are your only means of escape. • Exits and corridors should be kept clear of equipment

and furniture • Never prop or block doors from closing properly


Fire Alarm System • The alarm is activated if it senses smoke, water flow in

sprinkler pipers, or if a manual pull alarm is activated. • Manual pull alarms are located throughout the facility and

are red in color • Alarms will continue to sound until silenced by the

building manager • Flashing visual alarms are provided • Sprinklers are only activated by heat.


Fire Drills • Fire drills ensure the efficient and safe use of the exit facilities

available in the case of an emergency • Proper drills ensure the orderly exit under a controlled

environment and prevent the panic that has been responsible for much of the loss of life in major fire disasters.

• Never assume the alarm is a “drill” • Please refrain from “hiding” in cubicles, offices, conference

rooms or bathrooms. Employees found doing so, will be subject to corrective action.


Controlling a Fire • Do not attempt to fight a fire unless you are

absolutely sure you can put the fire out, AND • You will not endanger yourself or others.


Controlling a Fire When confronted with a fire, use the acronym RACE to

remember the correct procedure to follow: • Rescue those in immediate danger • Alarm others in the area by activating the nearest fire

alarm • Confine the fire and Call 911 • Extinguish the fire if small or Evacuate


Controlling a Fire • Pull the nearest fire alarm and call 911. • Control a fire with a fire extinguisher if you have been

trained. • Do not endanger your own safety! • Do not run with burning articles! • Close all doors in the area of the fire. • Move combustible items away from the fire. • Shut off unnecessary electrical equipment.


Fire Extinguishers – “PASS” Method • Pull the pin. Hold the extinguisher with nozzle

pointing away from you and release the locking mechanism.

• Aim low. Point the extinguisher at the base of the fire.

• Squeeze the lever slowly and evenly. • Sweep the nozzle from side to side.


Fire Extinguishers • In controlling a fire with an extinguisher

– Ensure that back-up extinguishers are available – Do not attempt to put out an overhead fire

• Access to fire extinguishers should remain unobstructed • Do not re-hang partially discharged extinguishers • Missing or discharged extinguishers should immediately

be reported to the building manager.


Emergency Generator System • Supplies emergency power if normal power is

disrupted. • Supplies power to emergency lighting and exit signs. • The emergency generators will activate and supply

power within 10 seconds of a disruption.


Emergency Generator System • Supplies emergency power if normal power is

disrupted. • Supplies power to emergency lighting and exit signs. • The emergency generators will activate and supply

power within 10 seconds of a disruption.


Employees are our greatest asset at CLINIC and we want everyone to be safe.

Thank you for completing this training!