FAQs

Standards Frequently Asked Questions
Comprehensive Accreditation Manual for Hospitals (CAMH)


Status Definitions


Ethics, Rights and Responsibilities


Individual Rights

Filming And RecordingEffectiveMar 07, 2005
Organ DonationEffectiveJan 17, 2006
Patient Rights and Informed Consent When Videotaping or FilmingUpdatedMar 15, 2002

Provision of Care


Assessment

Nutritional, Functional, And Pain Assessments And ScreensEffectiveFeb 17, 2004
Pre-Induction Assessment For Sedation And AnesthesiaRevisedApr 01, 2005
Updates to the Patient's ConditionRevisedApr 04, 2008
History And Physical For Hospital Outpatient ProceduresUpdatedJan 01, 2004
H&P from Non-Credentialed PractitionersUpdatedDec 17, 2007
History and Physical for SurgeryRevisedJun 16, 2006
Spiritual AssessmentRevisedJan 01, 2004
Authentication of H&P in 24 hoursRevisedApr 18, 2005
LPNs Performing AssessmentEffectiveSep 14, 2001
Breathalyzers, Continuous Glucose Monitoring Systems, Pulse Oximeters & Transcutaneous BilirubinometersRevisedApr 01, 2005
H&P Older Than 30 Days/Using the Prenatal RecordRevisedJan 01, 2004
Dictated History and PhysicalRevisedJan 01, 2004
Content of the History and PhysicalRevisedApr 01, 2005

Waived Testing

Waived Testing & Proficiency TestingNewAug 20, 2008
Patient/Client Self Glucose TestingRevisedApr 01, 2005
Physician Competency For Waived & P.P.M.P. TestingUpdatedJan 10, 2007
Survey Of Urine Drug Testing In A Behavioral Health Care FacilityEffectiveOct 31, 2006
Waived Testing LogsRevisedApr 01, 2005
Screening Vs. DefinitiveRevisedApr 01, 2005
Reference Ranges In Medical/Clinical RecordEffectiveJan 07, 2005
Reagents Stored With Medications Or SpecimensEffectiveJan 18, 2005
Professional Vs. Home Use Tests (Glucose Meters, Etc.)EffectiveOct 12, 2004
Provider Performed Microscopy Procedures (P.P.M.P.)RevisedApr 01, 2005
Color-Blind TestingEffectiveMay 29, 2003

Operative/High-Risk Procedures/Sedation/Anesthesia

Follow-up Phone Calls In Outpatient SurgeryEffectiveJan 22, 2004
Procedures Requiring Surgical Site MarkingUpdatedDec 16, 2004
Sedation and AnesthesiaEffectiveMar 26, 2001
Moderate Sedation Medication and Patient MonitoringRevisedJan 22, 2004
Permission to Administer Moderate SedationRevisedApr 13, 2005

Behavioral Health Care Restraint and Seclusion

Residents or House Staff Writing Orders and/or Evaluating a Patient for Restraint or Seclusion for Behavioral Health ReasonsUpdatedDec 11, 2001
Special Interventions (Behavioral Health Restraints & Seclusion)UpdatedApr 09, 2001
Restraint and SeclusionRevisedApr 01, 2005

Tissue Storage or Issuance

Applicability of the Tissue Storage & Issuance StandardsEffectiveApr 06, 2007
Autologous Bone FlapsEffectiveApr 06, 2007
Responsibility & OversightEffectiveApr 06, 2007
Tissue Source Facilities - Verification of Licensing & RegistrationEffectiveApr 06, 2007
Temperature Recording, Monitoring, Alarms and Back-Up StorageEffectiveApr 06, 2007
Verifying the Package upon ReceiptEffectiveApr 06, 2007
Tissue Redistribution to another Healthcare FacilityEffectiveApr 06, 2007
Traceability of RecordsEffectiveApr 06, 2007
Adverse Tissue Reaction PoliciesEffectiveApr 06, 2007

Medication Management


Patient-Specific Information

Minimum Patient Information - MedicationEffectiveJun 29, 2005

Selection and Procurement

Strength And Dosage Form ListingEffectiveAug 24, 2005
Monitoring Patient ResponseEffectiveAug 15, 2005
Medication Refrigerator Temperature LogsEffectiveAug 15, 2005
Annual Review of Formulary or Drug ListEffectiveAug 02, 2005
Define "Concentrated Kcl"EffectiveAug 04, 2005

Ordering and Transcribing

Diagnosis, Condition, Indication-For-Use In OrderEffectiveAug 08, 2005
Reordering Medications At TransferEffectiveAug 17, 2005

Preparing and Dispensing

Pharmacy Review For Licensed Independent Practitioner Controlled MedicationEffectiveAug 15, 2005
Labeling Medication For AnesthesiaEffectiveAug 15, 2005

Surveillance, Prevention and Control of Infection


The IC Program and Its Components

Licensed Independent Practitioner Health ScreeningEffectiveAug 02, 2006
Infection Control Applicability To Offsite Interpretive Reading ProvidersEffectiveMay 21, 2007
Food And Drinks In Patient Care AreasEffectiveJun 13, 2007

Leadership


Leadership

Credentialing And Privileging For Providers From Joint Commission Accredited OrganizationEffectiveJul 19, 2005
Annual Requirements in New StandardsRevisedFeb 15, 2005

Management of Environment of Care


Planning and Implementation Activities

Security of Syringes and NeedlesEffectiveOct 13, 2005
Temporary Construction BarriersRevisedApr 01, 2005
Eyewashes - Frequency of FlushingEffectiveJun 09, 2004
Trash CansRevisedApr 01, 2005
Blood Warmers - Alarm Check DocumentationEffectiveSep 29, 2004
Infant Abduction DrillsRevisedApr 01, 2005
Utility System and Acquired IllnessRevisedJan 01, 2004
Undersink StorageEffectiveApr 26, 2005
Tabletop DrillsEffectiveOct 31, 2005
Standpipe Fire Hose TestingRevisedApr 01, 2005
Staff Only RefrigeratorsEffectiveFeb 09, 2001
"Paper Patient" DrillsEffectiveNov 07, 2000
One-Time Extension Based on Unforeseen ConditionsEffectiveNov 07, 2000
Management Plans in Business OccupanciesRevisedApr 01, 2005
Hazardous MaterialEffectiveOct 31, 2000
Exit MapsEffectiveOct 31, 2000
Emergency ManagementRevisedApr 01, 2005
EC Management Plans in Several SettingsEffectiveFeb 09, 2001
Disaster DrillsRevisedApr 13, 2005

Management of Human Resources


Planning

Staffing EffectivenessEffectiveMay 01, 2006
Human Resource Standards Applicability to Contracted and Volunteer PersonnelUpdatedApr 01, 2005
Primary Source VerificationEffectiveApr 01, 2005
Requirements for Criminal Background ChecksRevisedApr 01, 2005

Management of Information


Confidentiality and Security

Medical Records Security After HoursUpdatedJun 13, 2007

Information Management Processes

Laboratory Report Requirements In The Medical RecordNewJul 18, 2008
Acceptable Abbreviation ListRevisedApr 01, 2005

Patient Specific Information

One LIP Signing for AnotherEffectiveFeb 14, 2002
Summary Lists - Divergent ComponentsEffectiveMay 04, 2005
Operative ReportsUpdatedMar 03, 2005
Authentication Using A Single DocumentRevisedApr 01, 2005
Ambulatory Summary ListEffectiveFeb 17, 2004
Authentication of the H&P in 24 HoursUpdatedMar 14, 2002
Authentication of DocumentationRevisedApr 13, 2005

Medical Staff


Continuing Education

Documenting CME'sEffectiveSep 11, 2007

Credentialing and Privileging and Appointment

Ongoing Professional Practice Evaluation (OPPE)NewAug 13, 2008
Primary Source Verification of Education for Licensed Independent PractionersEffectiveJan 04, 2008
Core/Bundled PrivilegesNewApr 01, 2008
Reappointment/Reprivileging DatesRevisedJan 01, 2004
Expediting the MEC FunctionEffectiveMar 11, 2002
Organ Procurement Team PrivilegingRevisedMar 05, 2007
Credentialing Non-Medical Staff Member Licensed Independent Practitioners Who Order tests and Treatments from a Joint Commission Accredited OrganizationRevisedJun 23, 2006
Provision of a Fair HearingUpdatedApr 13, 2005
Credentialing and Privileging in Hospital-Based* Long Term Care surveyed under the Comprehensive Accreditation Manual for Long Term CareRevisedJan 01, 2004
Credentialing and Privileging in Hospital-Based* Behavioral Health Care settings surveyed under the Comprehensive Accreditation Manual for Behavioral Health CareUpdatedMar 25, 2002
Verifying Work ExperienceRevisedApr 01, 2005
Verification of Credentials InformationEffectiveSep 14, 2001
Permission to Administer Moderate SedationRevisedApr 01, 2005
Peer ReferencesRevisedApr 01, 2005

Management of Patient Care, Treatment and Services

Medical Students Doing H&PRevisedMay 13, 2008
Podiatrist and Dentist Performing the Entire History and Physical for Inpatient and Outpatient CareRevisedJan 01, 2004
Delegation of the History and Physical ExaminationRevisedApr 01, 2005