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Policy & Procedures
    Clinic Manual




 ACTCM COMMUNITY CLINIC
        2011 -2012
                                                                           TABLE OF CONTENTS

1.0    MISSION STATEMENT ...........................................................................................................................................4
2.0    GENERAL ADMINISTRATION ............................................................................................................................5
      2.1 Organizational Chart .................................................................................................................................................................... 5
      2.2 Clinic Staff ............................................................................................................................................................................................. 5
      2.2.1 Dean of Clinical Education ................................................................................................................................................... 5
      2.2.3 Chief Academic and Clinical Advisor ................................................................................................................................... 7
      2.2.4 Responsibilities of Clinical Faculty (Supervisors) ........................................................................................................ 8
      2.2.5 Clinic Administrator ..................................................................................................................................................................... 9
      2.2.7 Clinic Receptionist .......................................................................................................................................................................10
      2.2.8 Clinic and Pharmacy Supply Coordinator......................................................................................................................11
      2.2.9 Student Liaison ............................................................................................................................................................................11
      2.3 Student Clinicians ...........................................................................................................................................................................11
      2.3.1 Student Conduct Within The Clinic ...................................................................................................................................19
      2.3.2 Required Clinical Hours for MSTCM students: Current Curriculum ....................................................................19
      2.3.4 Clinic Observational .................................................................................................................................................................27
      2.3.5 Trainee I...........................................................................................................................................................................................28
      2.3.6 Trainee II .......................................................................................................................................................................................29
      2.3.7 Trainee III .....................................................................................................................................................................................29
      2.3.8 Paired Clinic Intern.....................................................................................................................................................................30
      2.3.9 Clinic Intern .................................................................................................................................................................................30
      2.3.10 Case Study ..................................................................................................................................................................................30
      2.3.11 DAOM Students .......................................................................................................................................................................31
      2.3.13 Case Management ..................................................................................................................................................................39
      2.3.14 Externship ..................................................................................................................................................................................41
      2.3.15 Post-Graduate Fellowship ..................................................................................................................................................41
      2.3.16 Private Practice: Tui Na, Shiatsu, Acupuncture .........................................................................................................42
      2.3.17 Procedure for Notification of Clinic Absence and Complete Missed Clinic Hours .......................................42
      2.4 COMMITTEES...................................................................................................................................................................................44
      2.4.1 Quality Assurance Committee ..............................................................................................................................................44
      2.4.2 Student Peer Review Committee ........................................................................................................................................46
3.0    DAOM PROGRAM ................................................................................................................................................. 48
      3.1 DAOM Clinic Training ...................................................................................................................................................................48
      3.2 DAOM Clinic Forms........................................................................................................................................................................49
4.0    PATIENT CARE....................................................................................................................................................... 54
      3.1 Patient Care ....................................................................................................................................................................................54
      3.2 Patient Rights and Responsibilities ......................................................................................................................................55
      3.4 Refusal of Care................................................................................................................................................................................61
      3.5 Informed Consent ..........................................................................................................................................................................61
      3.6 Abuse, Misconduct, Harassment ...........................................................................................................................................62
      3.7 Patient Accounts and Billing......................................................................................................................................................64
      3.8 Health Insurance and Portability and Accountability Act (HIPAA) ........................................................................65
5.0    ACTCM COMMUNITY ACUPUNCTURE PROGRAM AND EXTERNSHIP SITES ........................................ 69
6.0    CLINIC PHARMACY .................................................................................................................................................. 71
      5.1 Organization ...................................................................................................................................................................................71
      5.2 Pharmacy Procedures .................................................................................................................................................................72
7.0    CLINICAL RECORDS AND CHARTING ................................................................................................................ 75

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8.0     MANDATORY REPORTING.................................................................................................................................... 96
       7.1 Domestic Abuse ..............................................................................................................................................................................97
       7.2 Child Abuse and Neglect Reporting Law ............................................................................................................................98
9.0     RISK MANAGEMENT PROGRAM ......................................................................................................................... 99
       8.1 Purpose ............................................................................................................................................................................................99
       8.2 Primary Goal ...................................................................................................................................................................................99
       8.3 Responsibility ..................................................................................................................................................................................99
       8.4 Compliance.................................................................................................................................................................................... 100
       8.5 Disciplinary Measures ........................................................................................................................................................... 100
       8.6 Communication ........................................................................................................................................................................ 100
       8.7 Hazard Assessment and Correction ..................................................................................................................................... 101
       8.8 Accident/Exposure Investigation ......................................................................................................................................... 104
       8.9 Training and Instruction .......................................................................................................................................................... 104
       8.10 Hazard Communication Program ..................................................................................................................................... 107
       8.12 Biohazard Safety........................................................................................................................................................................ 110
       8.13 Electrical Safety ....................................................................................................................................................................... 113
       8.14 Medical and First Aid............................................................................................................................................................. 113
       8.15 Fire Protection .......................................................................................................................................................................... 115
       8.16 Earthquake................................................................................................................................................................................. 115
       8.17 Video Display Terminals ...................................................................................................................................................... 115
       8.18 Water Supply and Sanitation ............................................................................................................................................ 116
       8.19 Workplace Security ................................................................................................................................................................ 116
       8.20 TUBERCULOSIS SURVEILLANCE PROGRAM .............................................................................................................. 117
10.0      EXPOSURE CONTROL PLAN ............................................................................................................................ 123
11.0      VARIANCE REPORTING .................................................................................................................................... 131
12.0     CLINIC POLICIES AND PROCEDURES ........................................................................................................... 137
       11.1 Punctuality .............................................................................................................................................................................. 137
       11.2    Enforcement standards for required signatures .................................................................................................. 137
       11.3 Absent Clinic Shift...................................................................................................................................................................... 137
       11.4 Clinic Supplies ............................................................................................................................................................................. 137
       11.5 E-community clinic for patients .................................................................................................................................... 138
       11.6 Emergency care .......................................................................................................................................................................... 138
13.0      POLICIES AND PROCEDURES MANUAL MAINTENANCE ........................................................................ 139
14.0      ADMINISTRATIVE PERSONNEL ..................................................................................................................... 140
15.0      APPENDIX ............................................................................................................................................................. 142




                                                                                                                                                                             Page 3 of 142
                         1.0 MISSION STATEMENT
  The Mission of the American College of Traditional Chinese Medicine is to provide exemplary
professional education and quality patient care in acupuncture and Traditional Chinese Medicine.




                                  VISION STATEMENT
The American College of Traditional Chinese Medicine will be the pre-eminent academic medical
        center for acupuncture and Traditional Chinese Medicine in North America.




                                      CORE VALUES
                  American College of Traditional Chinese Medicine values...

             Embracing the Philosophy and Spirit of Traditional Chinese Medicine

                                           Integrity

                                      Intellectual Freedom

                                           Diversity

                                            Respect

                                    Caring and Compassion

                                     Harmony and Balance




                                                                                Page 4 of 142
                                    2.0 General Administration

 2.1 Organizational Chart

                      Board of Directors



                      President



                      Clinic Dean                            Assistant Dean



Senior Academic                            Clinic
Advisor                                    Administrator




Clinic Teaching                            Acupuncturist
Faculty                                    Tui Na, Shiatsu, Reiki
                                           (Private Practice)




         Student
         Clinicians




Clinic Reception                    Supply                          Medical Insurance
                                    Coordinator                     Billing




 2.2 Clinic Staff

 2.2.1    Dean of Clinical Education

 The Dean of Clinical Education reports directly to the Provost /VPAA. The Dean is responsible for the
 administration and coordination of the College Clinic to maintain a safe, effective and professional
 operation of the clinic. The Dean works closely with the MSTCM Dean, college staff, students, patients,
 and clinic reception

 Responsibilities:

                                                                                        Page 5 of 142

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