Clinical Policies & Procedures

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Policy Suite

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Acute Pain Management

Advance Care Planning & Goals of Care Designation

Anaphylaxis Management: Administration of Intramuscular Epinephrine

Application of Topical Local Anesthetic for Potentially Painful Skin-Breaking Procedures

Appropriate Prioritization of Access to Health Services Policy

Bridge Supply and Pass Medications

Button Battery Ingestion - Pediatric

Canada-Global Rating Scale for Endoscopy

Cancer Drug Administration To Outpatients
Care of Late Preterm Infants

Chronic Disease Self-Management

Clinical Assessment of ‘At Risk” or Actual Preterm Labour for Triage

Complex & Essential Pediatric Medical Process

Clozapine Initiation, Maintenance, and Discontinuation

Consent to Treatment/Procedure(s)
Criteria to Support Appropriate Level of Obstetrical Care
Data Access & Use for Health System Improvement Purposes (Secondary Use)

Continuing Care Home Access and Waitlist Management

Developmental Care

Dispute Prevention & Resolution in Clinical Settings

Do Not Use List of Abbreviations, Symbols, & Dose Designations for Medication-Related Documentation

Donation After Cardiocirculatory Death (DCD)

External Beam Radiation Therapy Wait Time Access
Falls Risk Management

First Response to a Medical Emergency in Common Areas Inside of an AHS Facility or Outside within Close Proximity

Glycemic Management - Adult

Hand Hygiene

Handling of Transitory Audiovisual & Audio Recordings of Patients for Clinical Supervision

Psychoactive Substance Use

High-Alert Medication

Hyperbilirubinemia Screening, Assessment & Treatment – Well Newborn 35 0/7 Weeks Gestation & Greater

Independent Double-check
Individually Identifying Information

Induction of Labor

Influenza Immunization

Infusion Pumps for Medication & Parenteral Fluid Administration

Injectable Opioid Agonist Therapy Program
Insulin Pump Therapy in Hospital

Interaction between Alberta Health Services & Third Party Advocates

Intravenous Ketamine for Treatment-Resistant Depression

Invasive Infusion Line & Tubing Verification

Managed Risk Agreement

Management of Assistive Equipment & Technology - Continuing Care

Management of Cardiac Arrest When a Physician or Nurse Practitioner is Not Immediately Available

Management of Loaned, Reusable, Critical & Semi-Critical Medical Devices

Maternal & Infant Fall Prevention Management

  • Guideline Maternal & Infant Fall Prevention Management
  • Guideline: Care of the Infant After a Fall in Hospital

Medical Assistance in Dying

Medical Device Safety

Medication Administration

Medication Administration

Medication Administration - Seniors Health Continuing Care

Medication Management - Seniors Health Continuing Care

Medication Orders

Medication Reconciliation

Medication Samples

Missed Visit by Home Care Service Provider – Seniors Health Home Care

Naloxone Administration

Naloxone Administration for Opioid-Induced Respiratory Depression from Prescribed Opioids – Adult

Naloxone Distribution

Neonatal Abstinence Syndrome: Non-Pharmacological & Pharmacological Management, Assessment & Discharge - Infants Greater Than or Equal to 35 Weeks Gestation

Newborn Blood Spot Screening

Nitrous Oxide Use

Nurse Pronouncement of Patient Death
Obesity Medication Adjustment - Adult
Obstetrical Triage Acuity Scale (OTAS)

Oral Hygiene

Oxygen Therapy

Parenteral Nutrition

Patient Concerns Resolution

Patient Identification

Patient Repatriation

Patient Safety

Patient's Death in the Home Setting

Patient's Own Medications

Patients' Use of Cannabis for Medical Purposes
Pharmacist Administration of Intramuscular or Subcutaneous Medications
Pharmacist Ordering of Laboratory Tests
Pharmacist Prescribing of Medication Orders

Planning, Coordination, and Documentation of Treatment

Pneumococcal Immunization
Point of Care Testing (POCT)

Postpartum Depression Screening

Pre-Operative Fasting & Carbohydrate Loading Prior to Surgical Interventions - Adults

Prevention of Peripartum Acquired Group A Streptococcus

Procedural Sedation

Provincial Drug Formulary System

Quality Improvement

Registered Nurse or Registered Psychiatric Nurse Prescribing of Permitted Medications and Ordering of Diagnostic Tests

Residential Addiction Treatment & Detoxification Programs

Restraint as a Last Resort

Safe Bathing

Safe Infant Sleep

Safe Surgery Checklist

Critical and Semi-Critical Single Use Medical Devices

Skin Assessment

Standardized Medication Concentrations for Parenteral Administration

Suicide Risk Management

Supervised Exercise Program

Surgical Plume Management

Suspected Carbon Monoxide Exposure

Suspected Poisoning

Suspected Sepsis Assessment & Treatment in the Adult Patient

Termination of Pregnancy

Transfusion of Blood Components & Blood Products

Transportation of Patients

Treatment and/or Fever with Acetaminophen or Ibuprofen

Urgent Medical Attention for Individuals Apprehended Under the Mental Health Act

Venous Thromboembolism Prophylaxis

Family Presence

Waste Management

Well Infant Accommodation

Bariatric Response for Ground and Air Ambulance

Casual Employee Requirements

Cleaning and Disinfecting, Medical Equipment and Vehicles

Communication Manual

Controlled Drugs and Substances - Emergency Medical Services (EMS)

Emergency Medical Services (EMS) Transport Criteria to Urgent Care Centres

Emergency Medical Services Transfer of Patient Care to the Emergency Department Urgent Care Centre Triage Team

EMS Mobile Data Terminals

EMS Requests Related to Medical Assistance in Dying Events

EMS Roles - Medical Device Problems

Talkgroup Management

End of Shift Management
Filing Temporary Non-union Exempt Employee Reassignments

Geographically Challenging Patient Access / Back Country Rescue

Inter-Facility Transfers During Inclement Weather Situations

Just In Time Infusion Pump Training

Managing Patient Care Records
Performance and Response

Research and Other Knowledge Generating Activities

Return to Work Reorientation

Scene Safety Checks

Sick Leave

Time Off Requests

Uniform Standards

Vehicles

Controlled Substances

Newborn Admission and Nurse-Initiated Ordering at Time of Birth

Water Immersion Labour and Birth

Ground Inter-Facility Transfer: Newton’s Cradle

Clinically Complex Inter-Facility Patient Transport: Air Response Unavailable

Safe Use of Lasers

Infant Positioning for Neonatal Care

Pruritus Due To Acute Urticaria (Hives)

Glycemic Management - Pediatric

Autonomic Dysreflexia - Adult

STARS Stand Down

Insulin Adjustment - Pediatric

Assessment and Management of Antepartum Vaginal Bleeding

Abdominal Pain - Adult

Asthma Exacerbation - Adult

Blood Collection - Competency Requirements

Altered Level of Consciousness - Adult

Ambulatory Alcohol & Substance Withdrawal Management Including Induction of Opioid Agonist Treatment

Assessment & Reassessment of Patients

Dispensing of Medications to Patients with a Discharge Medication Order

Intranasal Medication Administration - Pediatrics

Intraosseous Vascular Access

Oral Fluid Rehydration for the Pediatric Patient

Oral Sucrose Administration - Pre-Procedural Analgesia

Supraglottic Airway Insertion By Registered Nurses

Searching Patients at Risk of Harming Themselves or Others

Spinal Motion Restriction

Suspected Fractured Hip - Adult Patients 50 Years of Age or Older

Suspected Ischemic Chest Pain

Flank Pain

Management of Chemical Exposure to the Eye(s)

Application of Topical Anesthetic Gel (LET) for Uncomplicated Lacerations

New Onset or Worsening Of Pre-Existing Dyspnea - Adult

Antiviral Prophylaxis for Health Care Workers During Influenza Outbreaks

Breastmilk Safe Management

Donor Human Milk

Surgical Site Verification and Marking for Surgical Interventions

Thresholds for Assigned Work Hours and Resource Utilization

Multiple Patient Inter-Facility Transport

Major Trauma - No Refusal
Management of Medications, Medical Supplies, and Intravenous Solutions

Diabetes Medication Adjustment – Adult
Acute Neurological Deficits - Adult
Hypertension and Preeclampsia in Obstetrical Outpatients - Initial Management

Interfacility Transfer or Discharge Transport for Medically Stable Patients

Care Transitions

Supervised Consumption Services - Calgary (Sheldon M. Chumir Health Centre), South Zone (Lethbridge Mobile Overdose Prevention Service)

Surgical Count

Breastfeeding

Inpatient Observation Levels, Off-Unit Access, & Passes

Safety Precautions

Suicide Risk Screening, Assessment & Management - Inpatient

Vaginal Bleeding

Suspected Hypovolemic or Hemorrhagic Shock

Gastrointestinal Bleeding

Unplanned Caesarean Delivery - Pre-Operative Preparation

Added or Extraordinary Care Funding

Appeal Panel Process

Chemoprophylaxis for Health Care Workers Exposed to Group A Streptococcus - Invasive (iGAS)

Mental Health Act Processes

Patient Access to Indigenous Spiritual Ceremony

Registered Nurse Prescribing First Line Osteoporosis Medication in High Fracture Risk Patients

Documentation of Response Outcome Codes

Seizure – Adult

Hypoglycemia Identification and Management in the Newborn Less Than 72 Hours of Age

Clinical Documentation

Safe Transitions

Anesthesia Care Team Roles and Responsibilities

Anesthesia Care Team Protocol for Maintenance of General Anesthesia

Anesthesia Care Team Protocol for Surgical Interventions with Peripheral Nerve Block or Neuraxial Anesthesia

Anesthesia Care Team Protocol for Ophthalmic Surgery

Animal Interactions, Personal Pet Visitation, and Qualified Assistance Dogs

Postpartum Hemorrhage: Early Recognition and Management

Asthma Exacerbation - Pediatric

Suspected Croup (Barky Cough) - Pediatric

Computerized Provider Order Entry (CPOE) System Alert Management