10A NCAC 14E .0303      POLICIES AND PROCEDURES and administrative records

(a)  The following essential documents and references shall be on file in the administrative office of the clinic:

(1)           documents evidencing control and ownerships, such as deeds, leases, or incorporation or partnership papers;

(2)           policies and procedures of the governing authority, as required by Rule .0302 of this Section;

(3)           minutes of the governing authority meetings;

(4)           minutes of the clinic's professional and administrative staff meetings;

(5)           a current copy of the rules of this Subchapter;

(6)           reports of inspections, reviews, and corrective actions taken related to licensure; and

(7)           contracts and agreements related to licensure to which the clinic is a party.

(b)  All operating licenses, permits, and certificates shall be displayed on the licensed premises.

(c)  The governing authority shall prepare a manual of clinic policies and procedures for use by employees, medical staff, and contractual physicians to assist them in understanding their responsibilities within the organizational framework of the clinic.  These shall include:

(1)           patient selection and exclusion criteria; and clinical discharge criteria;

(2)           policy and procedure for validating the full and true name of the patient;

(3)           policy and procedure for each type of abortion procedure performed at the clinic;

(4)           policy and procedure for the provision of patient privacy in the recovery area of the clinic;

(5)           protocol for determining gestational age as defined in Rule .0101(5) of this Subchapter;

(6)           protocol for referral of patients for whom services have been declined; and

(7)           protocol for discharge instructions that informs patients who to contact for post-procedural problems and questions.


History Note:        Authority G.S. 14‑45.1(a); 143B-10; S.L. 2013-366 s. 4(c);

Eff. February 1, 1976;

Readopted Eff. December 19, 1977;

Amended Eff. October 1, 2015; July 1, 1994.