Section 635.80 Written Policies, Protocols and Procedures of Delegate Agencies

Section 635

Section 635.80  Written

Policies, Protocols and Procedures of  Delegate Agencies

a)         The delegate agency must develop written policies, protocols

and procedures for family planning services.  Written policies, protocols and

procedures under which physicians, nurse practitioners, certified nurse

midwives, physician assistants and nutritionists provide family planning

services must be approved by the delegate agency's medical director.

b)         Policies regarding eligibility for services shall not exclude

anyone on the basis of duration of residency, age, race, marital status,

religion, color, national origin, creed, handicap, sex, number of pregnancies,

method of referral, or contraceptive preference.  Services shall be provided

only on a voluntary basis.  These documents shall be updated as needed based on

current state of the art in family planning and Federal and State Regulations.

Agency protocols will be subject to intensive review at site visits by

Department staff to determine their completeness and compliance with this Part.

c)         Written policies, protocols and procedures must include:

1)         Intake procedures for new clients

2)         Patient education

3)         Obtaining written informed consent

4)         Schedule and content of visits

A)        Initial

B)        Annual

C)        Scheduled return visits, specific to type of method of

contraception

D)        Problem visits, specific to type of problem

5)         Counseling procedures

6)         Referral procedures

7)         Follow-up procedures for appointments, failed appointments,

and referrals

8)         Maintenance of client records

9)         Approved medical orders

10)         Maintenance and distribution of pharmaceuticals

11)         Organizational structure of the unit and functional

responsibilities of medical, nursing and ancillary personnel

12)         Medical Procedures

A)        Pap smears and gonorrhea cultures

B)        Intrauterine device (IUD) insertions

C)        Fitting diaphragms/cer

enance of client records

9)         Approved medical orders

10)         Maintenance and distribution of pharmaceuticals

11)         Organizational structure of the unit and functional

responsibilities of medical, nursing and ancillary personnel

12)         Medical Procedures

A)        Pap smears and gonorrhea cultures

B)        Intrauterine device (IUD) insertions

C)        Fitting diaphragms/cervical caps

D)        Treatment of sexually transmitted diseases (STD)

E)        Initiating oral contraceptives

F)         Laboratory procedures

G)        Treatment of minor gynecologic problems

H)        Other medical procedures performed

13)         Release of patient records

14)         Emergency procedures