the pennine acute hospitals nhs trust and... · pennine acute hospitals nhs trust - list of live...

Pennine Acute Hospitals NHS Trust - List of Live Policies and Guidelines at end October 2017

NB: This list only reflects status as at the end of October 2017; documents can be updated or withdrawn at any time. page 1 of 50

Prepared by Policy Support, Division of Clinical Governance, ………….. 2017.

The Pennine Acute Hospitals NHS TrustList of 'Live' Policies, Protocols, Procedures, Patient Group Directions, &

Guidelines on Document Management System as at the end of October 2017.



Division Document Shelf Document Reference

Title Equality Impact Assessment included?

. Clinical Documents : Patient Group Directions : Integrated & PGD309 PGD309 for the administration of intra-articular

(Kenalog) triamcinolone acetonide injection to adult N/A

Anaesthesia & Surgery

Clinical Documents : Acute Illness Management CPDI083

intravascular devices and procedures for the preparation and administration of injectable pharmaceutical products; insertion, management

Yes


Clinical Documents : Acute Illness Management CPDI133 Adult Critical Care Outreach Services Operational

Policy Yes

Anaesthesia & Surgery Clinical Documents : Anaesthesia CPDI147 Anaphylactic Reactions Associated with

Anaesthesia: Management of Suspected Yes

Anaesthesia & Surgery Clinical Documents : Anaesthesia CPDI164 Hypotension Postoperatively; Management of Yes

Anaesthesia & Surgery Clinical Documents : Anaesthesia CPDI165 Low Body Mass Index (BMI); Management of

Patients with a low BMI Requiring Surgery Yes

Anaesthesia & Surgery Clinical Documents : Anaesthesia CPME141 Cortisol Deficiency in Adults (e.g. Addison's

Disease, hypopituitarism, adrenal suppression due Yes

Anaesthesia & Surgery Clinical Documents : Anaesthesia CPSU077 Lung Protective Ventilation & Treatment of Acute

Respiratory Distress Syndrome in Intensive Care Yes

Anaesthesia & Surgery Clinical Documents : Anaesthesia CPSU083 Invasive Procedures; safety standards for Yes

Anaesthesia & Surgery Clinical Documents : Anaesthesia CPSU086 Malignant Hyperthermia; Anaesthesia Emergency

Treatment and Management of Known Cases Yes

Anaesthesia & Surgery Clinical Documents : Anaesthesia CPWC059 Difficult Airway and Failed Intubation (for use in

Obstetric Theatres) Yes

Anaesthesia & Surgery Clinical Documents : Anaesthesia DGWC001

Staffing Levels; Governing Safe Staffing Levels for Obstetric Anaesthetists & Assistants on Labour Ward

Yes

Anaesthesia & Surgery Clinical Documents : Anaesthesia DPGDI024 Anaesthesia; Minimum ages of paediatric patients

undergoing Yes

Anaesthesia & Surgery Clinical Documents : Anaesthesia DPGDI027 Anaesthetic Preoperative Assessment; Location of Yes

Anaesthesia & Surgery Clinical Documents : Critical Care CPDI013 Critical Care; Adult Yes

Anaesthesia & Surgery Clinical Documents : Critical Care CPDI084 Intra-arterial Devices for Blood Pressure Monitoring

& Arterial Blood Sampling in adult patients; Yes

Anaesthesia & Surgery Clinical Documents : Critical Care CPDI095

Continuous Positive Airway Pressure (CPAP) in Acute Type I Respiratory Failure Patients within Critical Care /J4 Hi-Care; Institution of

Yes

Anaesthesia & Surgery Clinical Documents : Critical Care CPDI096

Non Invasive Ventilation (NIV) in Adult Patients with Acute Type 2 Respiratory Failure in Acute Wards & Level 2 Critical Care Areas; Use of

Yes

Anaesthesia & Surgery Clinical Documents : Critical Care CPDI198 Mechanical Ventilation on the Intensive Care Units;

Weaning of Adult Patients from Yes

Anaesthesia & Surgery Clinical Documents : Critical Care CPDI215 Sedation & Analgesia within Critical Care Yes

Anaesthesia & Surgery Clinical Documents : Critical Care CPSU075 Tracheostomy including the Tracheostomy Care

Bundle and Emergency Algorithms: Management of Yes

Anaesthesia & Surgery Clinical Documents : Critical Care EDC047 Organ Donation & Required Referral Yes


Clinical Documents : Gastroenterology CPME148 Ulcerative Colitis; The Management of Acute

Severe Yes


Clinical Documents : Gastroenterology CPSU009 Ascitic Drains for Abdominal Paracentesis;

Insertion, Management and Removal of Yes


Clinical Documents : Medicine Management EDT020 Proton Pump Inhibitors in Relation to Clostridium

difficile Associated Diarrhoea; Prescribing Yes

Anaesthesia & Surgery Clinical Documents : Nursing CPDI044 Patient Observation Practice; Standard for Yes


Clinical Documents : Nursing : Clinical Nursing Procedures NPDI002 Flexi Seal Faecal Management System; Insertion &

Management of the Yes


Clinical Documents : Nursing : Renal Procedures CPME056 Collective Renal Protocols for Managing

Intermittent Haemodiafiltration Treatment on Critical Yes


Clinical Documents : Pain Management : Adult Pain CPDI033 Spinal; Post Operative Management of Intrathecal

Local Anaesthetics & Opioids in Adults to Produce Yes

List of 'Live' Policies, Protocols, Procedures & Guidelines on Document Management System for Pennine Acute Hospitals NHS Trust as at end of October 2017

NB: This list does not include templates, nursing documentation, prescriber updates, service continuity plans, leaflets, alerts or other documents.






Clinical Documents : Patient Group Directions : Anaesthesia & PGD063 PGD063 Administration of Midazolam Injection by

Nurse Endoscopist N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD064 PGD064 Administration of Flumazenil Injection by

the Nurse Endoscopist N/A


Clinical Documents : Patient Group Directions : Anaesthesia & Surgery

PGD067PGD067 Administration of Intravenous 0.9% Sodium Chloride to an Adult Patient in a Medical Emergency

N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD076 PGD076 for the Administration of Oxygen to a

Patient within the Endoscopy Environment N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD077 PGD077 for the Supply & Administration of a

Disposable Phosphate Enema by Registered N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD078 PGD078 for Administration of Xylocaine Spray

(Lidocaine) by Nurse Endoscopist & Registered N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD128 PGD128 Administration of Hyoscine N Butyl

Bromide by Nurse Endoscopists N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD163 PGD163 Administration of intravenous Hartmann's

solution to adult patients in an emergency N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD236 PGD236 Administration of oral paracetamol

tablets/soluble tablets for adult postoperative day N/A



PGD237 PGD237 Administration of instillagel to adults for urethral catheterisation N/A



PGD238 PGD238 Administration of Tetracaine 4% gel (Ametop) to children and adults for cannulation N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD260 PGD260 Chlorhexidine Gluconate 4% Solution N/A



PGD261 PGD261 Mupirocin 2% Nasal Ointment N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD262 PGD262 Chlorhexidine Gluconate 0.2% Mouthwash N/A



PGD263 PGD263 Naseptin Nasal Cream (Chlorhexidine 0.1% and Neomycin 0.5% cream) N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD283 PGD283 Dispense & administer moviprep bowel

preparation for colonic imaging by registered N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD287 PGD287 for the Supply & Administration of Entonox

during Endoscopic Procedures by Registered N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD294 PGD294 for 20% Human Albumin Solution for

Albumin Replacement during Abdominal N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD295 PGD295 for pre procedure administration of oral

paracetamol tablets/soluble tablets for adult N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD296 PGD296 for pre procedure administration of per

rectum diclofenac for adult patients undergoing N/A



PGD299PGD299 Administration of Intramuscular Gentamicin For adult patients undergoing Lithotripsy treatment

N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD300 PGD300 Administration of Oral Co-Codamol tablets

/ Soluble Tablets for adult patients undergoing N/A


Clinical Documents : Respiratory/Oncology/Palliative Care : Respiratory

CPDI047 Domiciliary Ventilated Patients Accompanied by Carers to Support 24hr Care; Admission of Adult Yes

Anaesthesia & Surgery Clinical Documents : Surgery CPSU002 Vascular Patient; Initial Management & Transfer of

the Emergency Yes

Anaesthesia & Surgery Clinical Documents : Surgery CPSU017

Venous Thromboembolism (deep vein thrombosis & pulmonary embolism) In Patients 18 years of age & over admitted to hospital; Prevention of

Yes

Anaesthesia & Surgery Clinical Documents : Surgery CPSU019 Peri-operative Fasting in Adults and Children Yes

Anaesthesia & Surgery Clinical Documents : Surgery CPSU055 Pregnancy Testing in Patients Scheduled for

Procedures under General & Regional Anaesthesia Yes

Anaesthesia & Surgery Clinical Documents : Surgery CPSU056 Latex Allergy Screening in the Pre-operative

Assessment Clinic Yes

Anaesthesia & Surgery Clinical Documents : Surgery CPSU058 Obese Patients Requiring Surgery; Care

Management of Yes

Anaesthesia & Surgery Clinical Documents : Surgery CPSU060 Balloon Gastrostomy Tube into a Gastrostomy or

Jejunostomy; The insertion of Yes





Anaesthesia & Surgery Clinical Documents : Surgery CPSU067

Deep Vein Thrombosis and Pulmonary Embolism in Adult Inpatients & Outpatients; diagnosis & management of

Yes

Anaesthesia & Surgery Clinical Documents : Surgery CPSU079 Surgical Skin Site Preparation Yes

Anaesthesia & Surgery Clinical Documents : Surgery CPSU082 Operating Theatre Department, Standard Operating

Practice in the Yes

Anaesthesia & Surgery Clinical Documents : Surgery DGSU004 Electro Surgery Yes

Anaesthesia & Surgery Clinical Documents : Surgery EDC063 Arterial Thrombolysis Yes

Anaesthesia & Surgery Clinical Documents : Surgery NCSU004 Cancelled Operations Yes

Anaesthesia & Surgery Clinical Documents : Surgery NCSU018 Correct Patient, Procedure and Site Surgery Yes


Clinical Documents : Surgery : Theatres CPDI136

intravenous opioids postoperatively in theatre recovery by the recovery nurse/operating department practitioner

Yes


Clinical Documents : Surgery : Theatres CPSU018 Laryngeal Masks Yes


Clinical Documents : Surgery : Theatres CPSU025 Handover from Recovery Staff to Ward Staff Yes


Clinical Documents : Surgery : Theatres CPSU035 Endotracheal Tube in Recovery Unit - Adults only;

Removal of Yes


Clinical Documents : Surgery : Theatres CPSU037 Peri-operative Drug Administration Yes


Clinical Documents : Surgery : Theatres CPSU038 Theatre Safe Handling & Collection of Specimens Yes


Clinical Documents : Surgery : Theatres CPSU052 Latex Allergy Cases in Theatres Yes


Clinical Documents : Surgery : Theatres CPSU054 Day Surgery Unit Record Yes


Clinical Documents : Surgery : Theatres CPSU066 Day Surgery Minor / Clinic Procedure Record Yes


Clinical Documents : Surgery : Theatres CPSU078 Death in Theatre; Management of Yes


Clinical Documents : Surgery : Theatres CPSU085 23 hour Surgical Unit on the Rochdale site,

Operational Policy for Yes


Clinical Documents : Surgery : Theatres DGSU007 Time Owing Operating Theatres Yes


Clinical Documents : Surgery : Theatres DGSU010 Code of Practice Advanced Scrub Practitioner,

Theatre Department Yes


Clinical Documents : Surgery : Theatres DPSU003 Booking Emergencies in the Theatre Department -

Oldham & North Manchester sites only Yes


Clinical Documents : Surgery : Theatres NCPDI001 Spillage in the Operating Department; Management

of Yes


Clinical Documents : Surgery : Theatres NCSU014 Theatre Co-ordinator: Operational Policy for Yes


Clinical Documents : Surgery : Theatres NCSU016 Peri-Operative Record: Operating Department Yes


Clinical Documents : Surgery : Theatres NCSU021 Warming Devices within the Theatre Department;

Use of Yes


Clinical Documents : Surgery : Theatres NCSU022 Aestiva 5 Induction Machine incorporating the

VentiPac, AlarmPac & GE Patient Monitoring, Yes


Clinical Documents : Surgery : Theatres NCSU023 Theatre Department Equipment Failure Yes


Clinical Documents : Surgery : Theatres NCSU025 Avance Anaesthetic Machine Pre-Operative

Checks (incorporating GE patient monitoring) Royal Yes


Clinical Documents : Surgery : Theatres NCSU027 Theatre; Management of Elective Operating Lists Yes






Clinical Documents : Surgery : Urology CPSU051 Single Intravesicle Instillation of Mitomycin C using

a Mito-in Device; Administration of Yes


Clinical Documents : Surgery : Urology CPSU070 Supra Pubic Catheter; Insertion of Yes


Non Clinical Documents : Workforce & OD : Learning & OD CPME018 Arterial Blood Sampling in Adult Patients Skills

Development Workbook Yes

Chairman & CEO Office

Non Clinical Documents : General Trust Policies EDF007 Charitable Fundraising Guidelines Yes


Non Clinical Documents : General Trust Policies EDG032 VIPs: Handling of High Profile Visitors & the Media

to the Trust N/A


Non Clinical Documents : General Trust Policies EDG034 Board Assurance Framework No


Non Clinical Documents : General Trust Policies EDH038 Media Yes


Non Clinical Documents : General Trust Policies EDQ003 Freedom of Information Act Yes


Non Clinical Documents : General Trust Policies EDQ014 Records Management Yes


Non Clinical Documents : Governance EDQ028 External Agency Visits, Inspections, Accreditations

& National Reports; Responding to the Yes

Chairman & CEO Office Northern Care Alliance NCAG001 Fit & Proper Persons Yes

Chairman & CEO Office Northern Care Alliance NCAG002

Group Governance Framework Manual (incorporating Standing Orders of the Board of Directors, Standing Orders of the Council of

Yes

Diagnostics & Clinical Support

Clinical Documents : Medicine Management CPDI227 Vitamin D Deficiency in Adults, Children &

Pregnancy, Management of Yes

Elective Access Non Clinical Documents : General Trust Policies EDM006 Elective Access Yes

Elective Access Non Clinical Documents : Health Records EDM004 Overseas Visitors Yes

Elective Access Non Clinical Documents : Health EDM008 Health Records; Patient Yes

Elective Access Non Clinical Documents : Health Records EDM011 Health Records Service Yes

Elective Access Non Clinical Documents : Health Records EDM012 Health Records: Access to (Subject Access

Requests) Yes

Elective Access Non Clinical Documents : Health Records EDM014 Postal Items; Addressing of Internal & External Yes

Elective Access Non Clinical Documents : Miscellaneous (Non Clinical) EDM021 Cancer Access Yes

Finance and IM&T Services

Non Clinical Documents : General Trust Policies EDE041 Sustainable Procurement Yes

Finance and IM&T Services

Non Clinical Documents : General Trust Policies EDF004 Anti Fraud, Bribery and Corruption; Local Policy

and Response Plan Yes

Integrated Community Services

Clinical Documents : Critical Care CPDI065 Enteral Feeding Adults in Critical Care Yes

Integrated Community

Clinical Documents : General Medicine CPME054 Hot Joint: Early Management of the Acute Yes


Clinical Documents : Miscellaneous (Clinical) CPDI210 Diabetic Charcot Neuroarthropathy; Management of Yes


Clinical Documents : Nursing : Clinical Nursing Procedures CPIC006 Adult Nasogastric/Orogastric Feeding & Drainage

Tubes, Management of Yes


Clinical Documents : Nutrition & Dietetics

CPDI148 Overview

Nutrition Support in Adults Part 0: Hospital Setting Guideline Overview Yes


Clinical Documents : Nutrition & Dietetics CPDI148 Part 1 Nutrition Support in Adults Part 1: Guidelines for the

Management of Nutritional Screening, Assessment Yes


Clinical Documents : Nutrition & Dietetics CPDI148 Part 2 Nutrition Support in Adults Part 2: Guidelines for

Oral Nutrition Support Yes


Clinical Documents : Nutrition & Dietetics CPDI148 Part 3 Nutrition Support In Adults Part 3 Guidelines for

Enteral Tube Feeding Yes


Clinical Documents : Nutrition & Dietetics CPDI148 Part 4 Nutrition Support In Adults Part 4: Guidelines for

Parenteral Nutrition Yes


Clinical Documents : Nutrition & Dietetics CPDI148 Part 5 Nutrition Support in Adults Part 5: Refeeding

Syndrome in Adult Patients; Management of Yes






Clinical Documents : Nutrition & Dietetics CPDI181 Dysphagia; Management of Adult Patients with Yes


Clinical Documents : Nutrition & Dietetics NCPDI002 Enteral Feed for Adults; Procedures relating to the

supply of Yes


Clinical Documents : Pain Management : Adult Pain CPDI010 Analgesia Infusion in Adults: Patient Controlled Yes


Clinical Documents : Pain Management : Adult Pain CPDI042 Entonox - Inhalational Analgesia (Nitrous Oxide

50%/Oxygen 50%); Care of Adult Patient during Yes


Clinical Documents : Pain Management : Adult Pain CPDI073 Epidural Infusion Analgesia, Management of Adult

Patients with Yes


Clinical Documents : Pain Management : Adult Pain CPDI098 Acupuncture Clinics; Nurse Led Yes


Clinical Documents : Pain Management : Adult Pain Management

CPDI129Anaesthetic Infusions; Continuous infusion & boluses of Local Anaesthetic via an indwelling wound catheter (excluding epidural infusions)

Yes


Clinical Documents : Pain Management : Adult Pain Management

CPDI159 Pain in Adult inpatient aged over 18 years; Assessment & Management of Yes



PGD106PGD106 Administration of Oxybuprocaine Hydrochloride (Benoxinate 0.4%) Eye Drops Prior to Biometry

N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD136 PGD136 Administration of Tropicamide 1% &

Phenylephedrine 2.5% Eye drops prior to Fundus N/A


Clinical Documents : Patient Group Directions : Anaesthesia & PGD290 PGD290 for Administration of Lidocaine

Hydrochloride 4% with Fluorescein Sodium 0.25% N/A


Clinical Documents : Patient Group Directions : Integrated & PGD115 PGD115 Administration of Lidocaine Injection to

adult patients with joint inflammation & soft tissue N/A


Clinical Documents : Patient Group Directions : Integrated & PGD121 PGD121 Administration of Benoxinate

(Oxybuprocaine) Hydrochloride 0.4% w/v Prior to N/A


Clinical Documents : Patient Group Directions : Integrated & Community Services

PGD161 PGD161 Administration of Cyclopentolate & Phenylephrine in Children’s Ophthalmology Clinic N/A


Clinical Documents : Patient Group Directions : Integrated & PGD186 PGD186 for Co-amoxiclav 625mg tablets & Co-

amoxiclav 250/62 & 125/31 liquid for Animal & N/A

Integrated Clinical Documents : Patient PGD191 PGD191 Flucloxacillin Capsules & Syrup for N/AIntegrated Community

Clinical Documents : Patient Group Directions : Integrated & PGD192 PGD192 for supply of Flucloxacillin Capsules for

the Treatment of or Prophylaxis against Skin & Soft N/A


Clinical Documents : Patient Group Directions : Integrated & PGD194 PGD194 for Levonelle 1500 For Prevention of

Pregnancy following Unprotected Sexual N/A



PGD195 PGD195 for Lignocaine 1% for Local Infiltration N/A



PGD200 PGD200 for Paracetamol Tablets & Suspension for the Treatment of Mild to Moderate Pain or Pyrexia N/A


Clinical Documents : Patient Group Directions : Integrated & PGD201 PGD201 for supply of Penicillin V tablets for the

treatment of Bacterial Sore Throat in Adults N/A


Clinical Documents : Patient Group Directions : Integrated & PGD203 PGD203 for Absorbed Diphtheria (low dose),

tetanus and poliomyelitis (inactivated) vaccine N/A


Clinical Documents : Patient Group Directions : Integrated & PGD205 PGD205 for Human Tetanus Immunoglobulin BP

for Tetanus Prone Injuries N/A


Clinical Documents : Patient Group Directions : Integrated & PGD209 PGD209 for the Administration of Fluorescein

Sodium 1% Eye Drops for the Diagnostic N/A



PGD210 PGD210 for Fusidic Acid 1% Eye Drops (Fucithalmic) for Superficial Ocular Infections N/A



PGD212 PGD212 for Glyceryl Trinitrate Spray N/A


Clinical Documents : Patient Group Directions : Integrated & PGD214 PGD214 for Administration of Salbutamol Solution

for Nebulisation N/A


Clinical Documents : Patient Group Directions : Integrated & PGD215 PGD215 for Chlorphenamine Tablets &/ or Syrup

for Relief of Allergic Symptoms N/A



PGD218 PGD218 for Chloramphenicol 0.5% Eye Drops to patients with Bacterial Conjunctivitis N/A



PGD219PGD219 for Chloramphenicol 1% Eye Ointment for Bacterial Conjunctivitis & Superficial Ocular Infections including Prophylaxis in Corneal

N/A







PGD220PGD220 for Aspirin Dispersable Tablets 300mg for Management of Patients with Suspected Ischaemic Chest Pain

N/A


Clinical Documents : Patient Group Directions : Integrated & PGD221 PGD221 for Glucogel in Patients with Diabetes N/A


Clinical Documents : Patient Group Directions : Integrated & PGD239 PGD239 for Administration by Podiatrists of

Triamcinolone Acetonide Intra-articular, Peri- N/A



PGD243PGD243 for supply of Hydrocortisone 1% & Gentamicin 0.3% (Gentisone HC) Ear Drops for Otitis Externa

N/A



PGD284 PGD284 Administration of Naloxone to adult patients in an emergency situation N/A



PGD285PGD285 Administration of Lidocaine 5% and Phenylephrine 0.5% Topical Solution for local anaesthesia prior to Fibreoptic Endoscopic

N/A


Clinical Documents : Patient Group Directions : Integrated & PGD308 PGD308 for the administration of intra-articular

(Depo-medrone) methylprednisolone with lidocaine N/A


Clinical Documents : Patient Group Directions : Integrated & PGD310 PGD310 for the administration of intramuscular

(Depo-medrone) methylprednisolone to adults for N/A



PGD311PGD311 for the administration of intramuscular (Kenalog) triamcinolone to adults for the management of active inflammatory

N/A


Clinical Documents : Patient Group Directions : Integrated & PGD312 PGD312 for the administration of Hydrocortistab

injection to adult patients with joint inflammation N/A


Clinical Documents : Patient Group Directions : Integrated & PGD313 PGD313 for the administration of Triamcinolone

Acetonide to adult patients with joint inflammation N/A


Clinical Documents : Patient Group Directions : Integrated & PGD314 PGD314 for Administration of intramuscular (or

subcutaneous) inactivated influenza vaccine to N/A


Clinical Documents : Patient Group Directions : Integrated & PGD317 PGD317 for the supply & dose adjustment of

Warfarin by Heywood, Middleton & Rochdale N/A

Integrated Community Clinical Documents : Radiology CPDI223 Pre-procedural management of anticoagulants &

antiplatelets in patients undergoing image guided Yes


Clinical Documents : Rehabilitation/Stroke/Rheumatolog CPME157 Rheumatology Patients; Use of Intravenous Iloprost

in Yes


Clinical Documents : Respiratory/Oncology/Palliative CPME175 Investigation and Management of Malignancy of

Unknown Origin (MUO) / Cancer of Unknown Yes


Clinical Documents : Respiratory/Oncology/Palliative Care : Palliative Care

EDC072 Palliative Care: Pain & Symptom Control Yes



EDN033 Death; Care After Yes



EDN065 Verification of Death by Registered Nurses Yes


Clinical Documents : Respiratory/Oncology/Palliative Care : Respiratory

CPME163 Oxygen Therapy for Patients with Interstitial Lung Disease; Assessment & Prescription of Home Yes


Clinical Documents : Surgery : Ophthalmology NPSU009 Fundus Fluorescein Angiography: Nurse-Led Yes

Medical Director Clinical Documents : Communication EDC067 Diagnostic Tests; Clinical Standards (Your request:

Your responsibility) Yes

Medical Director Clinical Documents : Miscellaneous (Clinical) EDM009 Private Care Whilst Receiving NHS Treatment;

Patients who want to pay for Additional Yes

Medical Director Clinical Documents : Miscellaneous (Clinical) EDM013 Private care in PAHNT Facilities; Patients receiving N/A

Medical Director Clinical Documents : Miscellaneous (Clinical) EDQ002 Consent to Examination or Treatment No

Medical Director Clinical Documents : Research & Development EDRD001 R&D - Preparation, Approval & Maintenance of

R&D SOPs Yes

Medical Director Clinical Documents : Research & Development EDRD002 Ethical Review & Approval; Applications for Yes

Medical Director Clinical Documents : Research & Development EDRD003 R&D - Approval of Non NIHR CRN Research

Studies Yes

Medical Director Clinical Documents : Research & Development EDRD004 R&D - Approval of NIHR CRN (Portfolio) Research

Studies Yes





Medical Director Clinical Documents : Research & Development EDRD005 R&D - Definition of Responsibilities Yes

Medical Director Clinical Documents : Research & Development EDRD006 R&D - Study Initiation Yes

Medical Director Clinical Documents : Research & Development EDRD007 R&D - Study File & Filing Yes

Medical Director Clinical Documents : Research & Development EDRD008 R&D - Case Report Forms Yes

Medical Director Clinical Documents : Research & Development EDRD009 R&D - Informed Consent Yes

Medical Director Clinical Documents : Research & Development EDRD010 R&D - Informed Consent in Special Circumstances Yes

Medical Director Clinical Documents : Research & Development EDRD011 R&D - Safety Reporting Yes

Medical Director Clinical Documents : Research & Development EDRD012 Research Training Yes

Medical Director Clinical Documents : Research & Development EDRD013 R&D - External Monitoring Visits Yes

Medical Director Clinical Documents : Research & Development EDRD014 R&D - Preparing for Sponsor Audits and MHRA

Inspections Yes

Medical Director Clinical Documents : Research & Development EDRD015 R&D - Fraud, Misconduct & Serious Breach of

Good Clinical Practice Yes

Medical Director Clinical Documents : Research & Development EDRD016 R&D - Completion of a study Yes

Medical Director Clinical Documents : Research & Development EDRD017 R&D - Retention of Data, Archiving and Destroying

Documents Yes

Medical Director Clinical Documents : Research & Development EDRD018 R&D - Monitoring of Trust Sponsored Studies Yes

Medical Director Clinical Documents : Research & Development EDRD019 R&D - Auditing of Research Studies Hosted by the

Trust Yes

Medical Director Clinical Documents : Research & Development EDRD020 Research Governance Yes

Medical Director Non Clinical Documents : Governance : Risk Management EDQ043 Mortality Review No

Medical Director Non Clinical Documents : Miscellaneous (Non Clinical) EDC065 Medical Job Planning (Consultant & SAS) Yes

Medicine Clinical Documents : Acute Illness Management CPME172 Sepsis - Early Recognition and Management of

Adult Patients with Suspected Sepsis including Yes

Medicine Clinical Documents : Acute Illness Management EDC052 Major Trauma Team Yes

Medicine Clinical Documents : Cardiology CPME087Continuous Positive Airway Pressure (CPAP) Therapy using the Boussignac Valve & Pressure Manometer for Adult Patients with Acute

Yes

Medicine Clinical Documents : Cardiology CPME142 Implantable Cardioverter Defibrillators (ICD); Emergency Management of Patients with Yes

Medicine Clinical Documents : Cardiology CPME183Sacubitril Valsartan for the treatment of symptomatic chronic heart failure with reduced ejection fraction

Yes

Medicine Clinical Documents : EDC074 Outlying Surgical and Medical Patients Yes

Medicine Clinical Documents : Critical Care CPME133 Head Injury in Adult Patients: Assessment and Early Management Yes

Medicine Clinical Documents : Diabetes & Endocrinology CPME022 Endocrine Test; Adult Yes

Medicine Clinical Documents : Diabetes & Endocrinology CPME023 Part1 Diabetes Adult Inpatient Protocols & Guidelines

Part 1: Diagnosis & General Management of Yes

Medicine Clinical Documents : Diabetes & Endocrinology

CPME023Overview

Diabetes Adult Inpatient Protocols & Guidelines Overview Yes





Medicine Clinical Documents : Diabetes & Endocrinology CPME023Part 2 Diabetes Adult Inpatient Protocols & Guidelines

Part 2: Hyperglycaemia & Treatments Yes


Part 3: Special Inpatient Circumstances: Illness, Yes


Part 4: Diabetic Emergencies: Diabetic Yes

Medicine Clinical Documents : Diabetes & Endocrinology CPME150 Insulin Pump Therapy in Adults; Guidelines for the

Provision & Management of Yes

Medicine Clinical Documents : Discharge NCME002 Discharge Yes

Medicine Clinical Documents : General Medicine CPDI156 Haematology Inpatients and Day Cases; Clinical Yes

Medicine Clinical Documents : General Medicine CPME140 Seizure Activity of Convulsive Status Epilepsy in

Adult Patients; Diagnosis, Treatment & Clinical Yes

Medicine Clinical Documents : General Medicine CPME176 FallSafe Yes

Medicine Clinical Documents : Infectious CPME036 Malaria Yes

Medicine Clinical Documents : Infectious Diseases CPME089 Viral Haemorrhagic Fever; Patients Assessed as

being at risk of N/A

Medicine Clinical Documents : Infectious Diseases EDN014 Tuberculosis Yes

Medicine Clinical Documents : Nursing : Heart Failure Nurse Protocols CPME055 Heart Failure Exercise Programme; Referral of

Patients onto the Yes

Medicine Clinical Documents : Nursing : Heart Failure Nurse Protocols CPME076 Beta Blockers in Patients with Chronic Heart Failure

by the Heart Failure Nurse Specialist; Use of Yes

Medicine Clinical Documents : Pathology : Haematology CPDI040 Rasburicase for the Prevention and Treatment of

Acute Tumor Lysis Syndrome; Use of Yes

Medicine Clinical Documents : Patient Group Directions : Integrated & PGD184 PGD184 for Amoxicillin Capsules & Amoxicillin

Suspension for Treating Acute Otitis Media N/A

Medicine Clinical Documents : Patient PGD015 PGD015 Administration of Oxygen in N/A

Medicine Clinical Documents : Patient Group Directions : Medicine PGD037 PGD037 for the Administration of Co-dydramol

10/500mg Tablets N/A

Medicine Clinical Documents : Patient Group Directions : Medicine PGD185 PGD185 for Administration of Oxybuprocaine

Hydrochloride 0.4% (Benoxinate) Eye Drops N/A

Medicine Clinical Documents : Patient Group Directions : Medicine PGD193 PGD193 for Ibruprofen Tablets & Ibuprofen Oral

Suspension for Mild to Moderate Pain & Pyrexia N/A

Medicine Clinical Documents : Patient Group Directions : Medicine PGD289 PGD289 for the Administration of Morphine

Sulphate for Injection N/A

Medicine Clinical Documents : Patient Group Directions : Medicine PGD291 PGD291 Intra-venous Teicoplanin N/A

MedicineClinical Documents : Rehabilitation/Stroke/Rheumatology : Stroke Services

CPME082 Stroke; assessment and treatment of stroke patients Yes

Medicine Clinical Documents : Rehabilitation/Stroke/Rheumatolog CPME174 Intracerebral Haemorrhage: Management of

Spontaneous ICH Yes

Medicine Clinical Documents : Respiratory/Oncology/Palliative EDC062 Acute Oncology Initial Management Yes

Medicine Clinical Documents : Respiratory/Oncology/Palliative EDC053 Palliative Care: Care in the last days of adult life Yes

Medicine Clinical Documents : Respiratory/Oncology/Palliative CPME025 Pleural Diseases; Management of Yes

Medicine Clinical Documents : Respiratory/Oncology/Palliative CPME083 Nebuliser Compressor Issue Yes

Medicine Clinical Documents : Respiratory/Oncology/Palliative CPME145 Prescription & Administration of Oxygen in Adults in

the Acute Setting Yes

Medicine Clinical Documents : Respiratory/Oncology/Palliative CPME168 Asthma; Acute Adult Yes

Medicine Clinical Documents : Resuscitation EDC015 Resuscitation Yes

Medicine Clinical Documents : Resuscitation EDC039 Unified Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Adult Yes

Nursing Clinical Documents : Infection Control CPDI006 Outbreak Control & Ward Closure Yes





Nursing Clinical Documents : Infection CPDI008 Clostridium Difficile Yes

Nursing Clinical Documents : Infection Control CPDI016 Diarrhoea & Vomiting Yes

Nursing Clinical Documents : Infection Control CPDI017 Isolation; Patient Isolation Yes

Nursing Clinical Documents : Infection Control CPDI023 Methicillin Resistant Staphylococcus Aureus

(MRSA) Policy Yes

Nursing Clinical Documents : Infection Control CPDI023 Supp1 MRSA ICP N/A

Nursing Clinical Documents : Infection Control CPDI085 Blood Cultures; Collection of Yes

Nursing Clinical Documents : Infection Control CPDI086 Standard Precautions Yes

Nursing Clinical Documents : Infection Control CPDI115 Surveillance and Notification Yes

Nursing Clinical Documents : Infection Control CPDI214 Policy for the Management and Control of

Carbapenemase Producing Enterobacteriaceae Yes

Nursing Clinical Documents : Infection Control EDN035 Aseptic Non Touch Technique (ANTT)® Yes

Nursing Clinical Documents : Miscellaneous (Clinical) EDG003 Bleep (for the call out of Medical staff) Yes

Nursing Clinical Documents : Nursing EDC003 Breaking Significant News Yes

Nursing Clinical Documents : Nursing EDC054 Clinical Communication/Handover Yes

Nursing Clinical Documents : Nursing EDC070 Escalation Policy & Reporting Procedure for Extended Patient Waits Yes

Nursing Clinical Documents : Nursing EDG019 Transfer; Adult Yes

Nursing Clinical Documents : Nursing EDN005 Bed Rails: Use of Yes

Nursing Clinical Documents : Nursing EDN007 Privacy and Dignity Yes

Nursing Clinical Documents : Nursing EDN009 Patient Identification Yes

Nursing Clinical Documents : Nursing EDN015 Visitors Policy & Visitor Code: Hospital Yes

Nursing Clinical Documents : Nursing EDN031 Medicines; Training in the safe administration of Yes

Nursing Clinical Documents : Nursing EDN038 Rostering; Nursing & Midwifery Yes

Nursing Clinical Documents : Nursing EDN039 Staffing Shortfalls; Escalation of Nursing & Midwifery Staffing Shortfalls & Booking of No

Nursing Clinical Documents : Nursing EDN041 Urinary Catheters, Insertion & Management of Yes

Nursing Clinical Documents : Nursing EDN051 Intentional rounding Yes

Nursing Clinical Documents : Nursing EDN054 Single Sex Accommodation Yes

Nursing Clinical Documents : Nursing EDN056 Nursing & Midwifery Council; Referral of a Registrant to the Yes

Nursing Clinical Documents : Nursing NCME001 Chaperone Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult CPME144 Alcohol Withdrawal Syndrome Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult DPWC011 Female Genital Mutilation; Safeguarding Guidelines

for Dealing with Actual or Suspected Cases of FGM Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDC057 Alcohol Strategy, Trustwide Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDC064 Mental Health Act 1983 Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDG030 Homelessness; Hospital Discharge Prevention of Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDN010 Safeguarding (Adult & Child Protection) Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDN036 Safeguarding Training (Adult & Child Protection /

Safeguarding) No

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDN037 Deprivation of Liberty Safeguards Yes





Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDN040 Abuse; Allegations Against Staff who Work with

Children & Adults at Risk (safeguarding) Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDN042 Domestic Abuse Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDN048 Learning Disability (Safeguarding) Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDN049 Restraint; Adult Patient Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDN050 Alcohol; Identification and Brief Advice (IBA) for Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDN052 Learning Disabilities and Autism Good Practice

Guidance; Care Pathway for People with Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDN055 Dementia Strategy Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDN057 E-Safety Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDN058 Patient Experience Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult EDQ029 Mental Capacity Act (Adult & Child Protection /

Safeguarding) Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult NCSU013 Missing Patient Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult NCWC010 Harm to Children, Young People and Vulnerable

Adults (Safeguarding); Management of Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Adult NCWC011 Protection of Adults at Risk of Abuse and Neglect

(Adult Safeguarding) Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Children DPWC008 Babies Being Transferred into the Care of the Local

Authorities Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Children EDG027 Child and Adult Safeguarding Supervision Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Children EDN047 Restraint & Holding Children Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Children EDN053 Admission of Children to Adult Wards Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Children NCWC001 Child Protection (Safeguarding) Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Children NCWC003 Fabricated and Induced Illness (Child Protection /

Safeguarding); Management of Yes

Nursing Clinical Documents : Safeguarding Vulnerable People : Children NCWC007 Child Protection Concerns (Child

Protection/Safeguarding): Hospital Discharge for Yes

Nursing Clinical Documents : Wound Management CPME001 Wound Management; Use of Negative Pressure

Wound Therapy in Yes

Nursing Clinical Documents : Wound Management CPME002 Pressure Ulcers; Prevention and Management of Yes

Nursing Clinical Documents : Wound Management CPME003 Wound Management; Use of Sterile Larvae in Yes

Nursing Clinical Documents : Wound Management CPME005 Leg Ulcers; Prevention and Management of Yes

Nursing Clinical Documents : Wound Management CPME024 Wounds; Prevention and Management of Yes

Nursing Clinical Documents : Wound Management CPME085 Aseptic Technique in Wound Management Yes

Nursing Non Clinical Documents : General Trust Policies EDG013 National Institute for Health and Clinical Excellence

Guidance; Implementation of Yes

Nursing Non Clinical Documents : General Trust Policies EDG014 Work Wear Yes

Nursing Non Clinical Documents : General Trust Policies EDG017 Enhanced Patient Observation Yes

Nursing Non Clinical Documents : General Trust Policies EDG022 Volunteer Yes

Nursing Non Clinical Documents : General Trust Policies EDN004 Clinical Record Keeping Yes





Nursing Non Clinical Documents : General Trust Policies EDN011 Religious & Faith Requirements Relevant to

Hospital Admissions; Guidance for Staff Yes

Nursing Non Clinical Documents : General Trust Policies EDN044 Carers 2013 - 2018 Yes

Nursing Non Clinical Documents : Governance EDG004 Complaints Handling Yes

Nursing Non Clinical Documents : Governance EDG010 Handling Clinical Negligence Claims, Liabilities to

Third Parties Claims (LTPS), Property Expenses Yes

Nursing Non Clinical Documents : Governance EDG016 Legal Advice Request Yes

Nursing Non Clinical Documents : Governance EDQ001 Document Control Yes

Nursing Non Clinical Documents : Governance EDQ006 Patient Information: Production of Yes

Nursing Non Clinical Documents : Governance EDQ025 Duty of Candour Yes

Nursing Non Clinical Documents : Governance EDQ032 Clinical Audit & Effectiveness Yes

Nursing Non Clinical Documents : Governance EDQ033 Clinical Audit & Effectiveness Yes

Nursing Non Clinical Documents : Governance EDQ037 Quality Improvement Strategy No

Nursing Non Clinical Documents : Governance : Health & Safety EDC040 Laser Yes

Nursing Non Clinical Documents : Governance : Health & Safety EDQ012 Risk Management Strategy & Yes

Nursing Non Clinical Documents : Governance : Health & Safety EDQ017 Alert Notices Generated Via the Central Alerting

System: Distribution & Management of Yes

Nursing Non Clinical Documents : Governance : Health & Safety EDQ035 Risk Assessment for New & Expectant Mothers Yes

Nursing Non Clinical Documents : Governance : Health & Safety EDQ038 Contractors; Control and Management of Yes

Nursing Non Clinical Documents : Governance : Health & Safety EDQ040 Health & Safety Strategy 2016-18 Yes

Nursing Non Clinical Documents : Governance : Health & Safety EDQ041 Stress at work; managing Yes

Nursing Non Clinical Documents : Governance : Risk Management EDQ008

Incident Reporting & Investigation; including Serious Incident Framework & Duty of Candour & Learning from Deaths

Yes

Nursing Non Clinical Documents : Governance : Risk Management EDQ039 Mortality Review Yes

Nursing Non Clinical Documents : Health and Safety EDQ007 Health and Safety Yes

Nursing Non Clinical Documents : Health and Safety EDQ016 Display Screen Equipment Yes

Nursing Non Clinical Documents : Health and Safety EDQ019 Slips Trips & Falls; Prevention of Staff & Visitor Yes

Nursing Non Clinical Documents : Health and Safety EDQ021 First Aid Yes

Nursing Non Clinical Documents : Health EDQ023 Latex; Management of Yes

Nursing Non Clinical Documents : Health and Safety EDQ026 sharps injury/exposure to blood and body fluids;

Prevention of Yes

Nursing Non Clinical Documents : Workforce & OD : Human EDH023 Interpretation & Translation Yes

Support Services

Clinical Documents : Community North Services CPDI176 Community Nurses Controlled Drugs Yes

Support Services

Clinical Documents : Community North Services CPDI187 Medicines Transcribing (for use by Community

Services North) Yes

Support Services

Clinical Documents : Community North Services CPDI191 Controlled Drugs Intermediate Care Units Yes

Support Services

Clinical Documents : Community North Services CPDI196 Medicines; for Community Staff Employed by PAT Yes





Support Services Clinical Documents : Critical Care CPME010 Intravenous Human Immunoglobulin Policy for

Adults Yes

Support Services Clinical Documents : HSDU EDE043 Decontamination of Re-usable Medical Devices Yes

Support Services

Clinical Documents : Infection Control EDE018 Trust Cleaning Yes

Support Services

Clinical Documents : Medicine Management CPDI180 Ulcerative Colitis; Administration of Intravenous

Ciclosporin in Acute Severe Yes

Support Services

Clinical Documents : Medicine Management CPDI222 Cardiology Continuous Infusion Charts Yes

Support Services

Clinical Documents : Medicine Management CPME177 Anticoagulation; Management of Oral

Anticoagulation in Patients with Atrial Fibrillation Yes

Support Services

Clinical Documents : Medicine Management EDC016 Transfer of Medicines Between Departments &

Wards When the Pharmacy is Closed Yes

Support Services

Clinical Documents : Medicine Management EDC017 Ordering, Storage and Administration of Controlled

Drugs Yes

Support Services

Clinical Documents : Medicine Management EDC018 Medicines Yes

Support Services

Clinical Documents : Medicine Management EDC020 Unauthorised Drugs or Other Unidentified

Substances brought in by Patients; Dealing with Yes

Support Services

Clinical Documents : Medicine Management EDC023 Medicines; Self Administration by Adult In-patients

of Yes

Support Services

Clinical Documents : Medicine Management EDC024 Medication to Patients Discharged Outside

Pharmacy Working Hours; Supply of Yes

Support Services

Clinical Documents : Medicine Management EDC025 Recorded Drugs; Ordering, Storage &

Administration of Yes

Support Services

Clinical Documents : Medicine Management EDC033 Non Medical Prescribing Yes

Support Services

Clinical Documents : Medicine Management EDT003 Intravenous Potassium Yes

Support Services

Clinical Documents : Medicine Management EDT004 Prescribed Medicines to Inpatients Yes

Support Services

Clinical Documents : Medicine Management EDT015 Vancomycin for ICU use; Continuous Infusion of Yes

Support Services

Clinical Documents : Miscellaneous (Clinical) CPDI155 Vaccinations in Infectious Diseases & Adult Travel

Outpatient Clinics; Stock Control, Prescription & Yes

Support Services

Clinical Documents : Miscellaneous (Clinical) EDC069 Admittance of Medical Device Company

Representatives to the Trust Yes

Support Services

Clinical Documents : Miscellaneous (Clinical) EDE012 Issue of Equipment to Home, Policy for Yes

Support Services

Clinical Documents : Miscellaneous (Clinical) EDE019 Medical Devices; Management & Use of Yes

Support Services

Clinical Documents : Miscellaneous (Clinical) EDE053 Medical Devices Involved in Incidents;

management of Yes

Support Services

Clinical Documents : Miscellaneous (Clinical) EDE056 Approval of changes or introduction of new medical

devices Yes

Support Services Clinical Documents : Pathology CPDI030 Post-Mortem Consent; Adult Hospital Yes

Support Services Clinical Documents : Pathology CPDI061 Labelling & Safe Handling of Pathology Samples &

Request Forms Yes

Support Services Clinical Documents : Pathology DPGDI028 Pathology Provision; Rochdale Infirmary Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion CPDI011 Platelet Transfusion in adults and children/neonates Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion CPDI012 Fresh Frozen Plasma components; use of Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion CPDI036 Special requirements for blood components,

Guideline for Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion CPDI043 Blood & Blood Components - Transfer Between

Hospitals within the Trust and other Hospitals Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion CPDI063 Blood Management - Patient Blood Management

prior to Surgery Yes





Support Services

Clinical Documents : Pathology : Blood Transfusion CPDI064 Blood Components; Management of All Patients

Who Decline (including Jehovah's Witnesses) Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion CPDI072 Cell Salvage; Provision of Autologous

Intraoperative & Postoperative Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion CPDI137 Human Albumin Solution 4.5% & 20%; Use of Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion CPDI182 Blood component transfusion; Senior Nurses and

Advanced Practitioners providing the written Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion CPDI201

Bleeding in patients receiving antithrombotic agents or who require emergency/elective anticoagulant reversal

Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion CPDI205 Blood Management - Patient Blood Management of

Medical Patients Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion CPWC149 Anaemia in Pregnancy & Post Partum; Prevention,

Screening, Investigation & Management of Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion EDC005 Transfusion Reactions; Management of Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion EDC006 Blood and Blood Components; Administration of Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion EDC007 Blood Transfusion; Indications for Red Cell

transfusion "The Green Policy" Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion EDC009 Blood: Management of a Massive Blood Loss Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion EDC011 Red Cells from the Blood Bank Fridge; Collection of Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion EDC012 Blood Samples for Transfusion Tests which

Generate a Blood Group; Requesting, Collecting, Yes

Support Services

Clinical Documents : Pathology : Blood Transfusion EDC031 Blood Stocks Management Plan: Emergency Yes

Support Services

Clinical Documents : Pathology : Haematology CPDI045 Chemotherapy for Adult Patients; Intrathecal

Cytotoxic Yes

Support Services

Clinical Documents : Pathology : Haematology CPDI069 Rituximab Infusions in the Treatment of Non-

Hodgkins Lymphoma; Administration of Yes

Support Clinical Documents : Pathology : CPDI024 Transmissible Spongiform Encephalopathies (TSE) YesSupport Services

Clinical Documents : Pathology : Point of Care Testing CPDI019 Point of Care Testing Yes

Support Services

Clinical Documents : Patient Group Directions CPDI105 Patient Group Directions Yes

Support Services

Clinical Documents : Patient Group Directions : Support PGD096 PGD096 The Supply and Dose Adjustment of

Warfarin N/A

Support Services

Clinical Documents : Patient Group Directions : Support PGD101 PGD101 The supply & administration of

Phytomenadione/Vitamin K (Konakion MM N/A

Support Services

Clinical Documents : Patient Group Directions : Support Services

PGD113PGD113 The supply & administration of Low Molecular Weight Heparin: Enoxaparin Sodium (Clexane injection) during the temporary

N/A

Support Services

Clinical Documents : Patient Group Directions : Support PGD133 PGD133 Administration by Radiographers of

Niopam (Iopamidol) as radiographic contrast agents N/A

Support Services

Clinical Documents : Patient Group Directions : Support PGD150 PGD150 Supply & Administration of Enoxaparin

Sodium (Clexane) for Patients with a Sub- N/A

Support Services


PGD160PGD160 Administration of Hyoscine Butylbromide for Radiological examination of the Gastrointestinal Tract

N/A

Support Services

Clinical Documents : Patient Group Directions : Support PGD230 PGD230 Administration by Radiographers of

ProHance (Gadoteriol) as a Radiographic Contrast N/A

Support Services


PGD231PGD231 Administration by Radiographers of MultiHance (Gadobenate dimeglumine) as a Radiographic Contrast Agent

N/A

Support Services


PGD240PGD240 PGD for Administration of Lidocaine 1% with Adrenaline (Epinephrine) 1:200000 for Use During Interventional Breast Procedures under

N/A

Support Services


PGD277 PGD277 Use of Glycerol Suppositories prior to lower GI investigations N/A

Support Services

Clinical Documents : Patient Group Directions : Support PGD279 PGD279 For Administration by Radiographers of

Omnipaque as Radiographic Contrast Agents for N/A

Support Services

Clinical Documents : Patient Group Directions : Support PGD282 PGD282 Barium Sulphate in video swallow

examinations by radiographers and speech and N/A





Support Services


PGD304PGD304 Administration by Radiographers of Primovist (Gadoxetate disodium) as a Radiographic Contrast Agents

N/A

Support Services

Clinical Documents : Patient Group Directions : Support PGD305 PGD305 Barium Sulphate in Barium Swallow

Examinations Performed by Radiographers. N/A

Support Services


PGD316PGD316 for Administration by Radiographers of Omnipaque (Iohexol) as a Radiographic Contrast Agent

N/A

Support Services Clinical Documents : Pharmacy CPDI111 Drug Prescription & Administration record; Use of

the PAHNT Yes

Support Services Clinical Documents : Pharmacy CPDI173 Opioid-dependent Adult Inpatients; Treatment &

Management of Yes

Support Services Clinical Documents : Pharmacy CPDI199

Parkinson's Disease in Patients who are nil by mouth (NBM) or have Compromised Swallow:Guideline for the Management of

Yes

Support Services Clinical Documents : Pharmacy CPME152 Stroke; Management of Hypertension Prior to

Thrombolysis in Patients with Acute Ischaemic Yes

Support Services Clinical Documents : Pharmacy EDT007 Antibiotic (Adult Patients) Yes

Support Services Clinical Documents : Pharmacy EDT010 Penicillin Allergy Yes

Support Services Clinical Documents : Pharmacy EDT017 Loading Doses; Adult Yes

Support Services Clinical Documents : Pharmacy EDT018 Medicines by Unregistered Practitioners;

Administration of No

Support Services Clinical Documents : Pharmacy EDT019 Electrolyte Disturbances; Treatment of Adult

Patients Management of Yes

Support Services Clinical Documents : Pharmacy EDT025 Medicines Optimisation Yes

Support Clinical Documents : Pharmacy EDT026 Antimicrobial Stewardship Yes

Support Services Clinical Documents : Radiology CPDI066 Radiology; Referral to by Non Medical Registered

Health professionals Yes

Support Services Clinical Documents : Radiology CPDI075 Breast Interventional Procedures; Protocol &

Scheme of Work for Consultant Yes

Support Services Clinical Documents : Radiology CPDI099 Referral for the Diagnostic Investigation of

Pulmonary Embolus Yes

Support Services Clinical Documents : Radiology CPDI109 Radiology Requests for Patients Deemed Unfit by

the Referrer; Return of Yes

Support Services Clinical Documents : Radiology CPDI110 Radiology Auto-reporting Yes

Support Services Clinical Documents : Radiology CPDI113 Ultrasound for Obstetrics & Gynaecology Yes

Support Services Clinical Documents : Radiology CPDI122 Cervical Spine Imaging Following Trauma in Adults Yes

Support Services Clinical Documents : Radiology CPDI140 Imaging of Patients with an Acute Stroke Yes

Support Services Clinical Documents : Radiology CPDI157 Radiographic Imaging & Reporting of Non-

Accidental Injury (NAI) Referrals (Child Protection / Yes

Support Services Clinical Documents : Radiology CPDI160 Nephropathy in Patients Undergoing Injection of

Radiographic Contrast Agents; Prevention of Yes

Support Services Clinical Documents : Radiology CPDI167

Magnetic Resonance Imaging for Patients Referred with Suspected Metastatic & Non-Metastatic Spinal Cord Compression

Yes

Support Services Clinical Documents : Radiology CPDI169 Reporting Protocol for Specialist Fluoroscopy

Radiographers Yes

Support Services Clinical Documents : Radiology CPDI174 Forensic Imaging Investigations Yes

Support Services Clinical Documents : Radiology CPDI178 CT; Whole Body Computed Tomography in Major

Trauma Yes

Support Services Clinical Documents : Radiology CPDI194 Radiology Internal Professional Standards:

Multidisciplinary Team Meeting Yes

Support Services Clinical Documents : Radiology CPDI200 Intravenous Opiates and Midazolam by Radiology

Nurses; Administration of Yes





Support Clinical Documents : Radiology CPDI213 Radiology Service; On Call General YesSupport Services Clinical Documents : Radiology CPDI217 Endovascular Aneurysm Repair Procedures

(EVAR); Management of Patients requiring Yes

Support Services Clinical Documents : Radiology CPDI218

Nephrostomy and Antegrade Ureteric Stent Insertion in Radiology, Standard Operating Procedure for

Yes

Support Services Clinical Documents : Radiology CPDI220 Radiation; Protection of Staff and Patients Exposed

to Ionising Radiation through the Work of the Yes

Support Services Clinical Documents : Radiology DPDI003 Radiology Reporting Yes

Support Services Clinical Documents : Radiology DPDI004 Ionising Radiation (Medical Exposure) Regulations

[IR(ME)R] Yes

Support Services Clinical Documents : Radiology DPGDI016 Children's Radiology; Operational Plan for NMGH Yes

Support Services Clinical Documents : Radiology DPGDI021 Diabetes Patients on Metformin: IV Contrast

Administration in Yes

Support Services Clinical Documents : Radiology DPGDI026 Nephrogenic Systemic Fibrosis (NSF) in Patients

Undergoing Injection of Gadolinium Contrast Media; Yes

Support Services

Clinical Documents : Surgery : Theatres NPDI004 Swabs, Sharps & Instruments; Checking of Yes

Support Services Emergency Plans CPME078 Pandemic Influenza; Guidance for the Management

of Yes

Support Services Emergency Plans EDE044 Lockdown Plan; Trust Generic Yes

Support Services Emergency Plans EDG006 Major Incident Plan: Fairfield General Hospital Yes

Support Services Emergency Plans EDG007 Major Incident Plan: North Manchester General

Hospital & Community Services Yes

Support Services Emergency Plans EDG008 Major Incident Plan: Rochdale Urgent Care Centre Yes

Support Services Emergency Plans EDG009 Major Incident Plan: Royal Oldham Hospital Yes

Support Services Emergency Plans EDG018 Rapid Discharge in Acute Settings: Emergency Yes

Support Services Emergency Plans EDG021 Recovery Plan Yes

Support Services Emergency Plans EDG025 Burns Major Incident Plan Yes

Support Services Emergency Plans EDG031 Evacuation (Trust Evacuation Strategy) Yes

Support Services Emergency Plans EDG033 Reserve Forces; employment of staff in the Yes

Support Services Emergency Plans EDI015 Service Continuity No

Support Services

Non Clinical Documents : General Trust Policies EDE001 Gas Systems; Piped Medical Yes

Support Services

Non Clinical Documents : General Trust Policies EDE010 Security Yes

Support Services

Non Clinical Documents : General Trust Policies EDE017 Vehicle Parking Yes

Support Services

Non Clinical Documents : General Trust Policies EDE022 Taxis: Use of Hospital & Community Yes

Support Services

Non Clinical Documents : General Trust Policies EDE023 Waste Management Yes

Support Services

Non Clinical Documents : General Trust Policies EDE030 Pest Control Yes

Support Services

Non Clinical Documents : General Trust Policies EDE031 Reactive and Planned Preventative Maintenance Yes

Support Services

Non Clinical Documents : General Trust Policies EDE032 Building and Refurbishment Yes

Support Services

Non Clinical Documents : General Trust Policies EDE045 Food and Nutritional Care for in-patients Yes





Support Non Clinical Documents : General EDE048 Laundry & Linen Services; Management of Yes

Support Services

Non Clinical Documents : General Trust Policies EDG002 Smoke Free Environment Yes

Support Services

Non Clinical Documents : General Trust Policies EDG012 Fire Safety Yes

Support Services

Non Clinical Documents : Health and Safety EDE008 Food Hygiene Codes of Practice Yes

Support Services

Non Clinical Documents : Health and Safety EDE014 Asbestos Management Yes

Support Services

Non Clinical Documents : Health and Safety EDE015 Water safety Yes

Support Services

Non Clinical Documents : Health and Safety EDE020 Medical Devices & Equipment; Training &

Assessment for Safe use of Yes

Support Services

Non Clinical Documents : Health and Safety EDE050 Electrical Safety (not including Medical Devices) No

Women & Children Clinical Documents : Gynaecology CPWC006 Miscarriage: Confirmed Non Viable Intrauterine

Pregnancy in the First Trimester Yes

Women & Children Clinical Documents : Gynaecology CPWC009 Nausea & Vomiting in Pregnancy up to 16 weeks

Gestation; Management of Yes

Women & Children Clinical Documents : Gynaecology CPWC010 Fetal Tissue up to 24 Completed Weeks Gestation;

Sensitive Disposal of N/A

Women & Children Clinical Documents : Gynaecology CPWC054 Medical Termination of Pregnancy in the Second &

Third Trimesters Yes

Women & Children Clinical Documents : Gynaecology CPWC143 Colposcopy Standards & Guidelines Yes

Women & Children Clinical Documents : Gynaecology CPWC177 Gynaecology pathway Emergency

Department/Urgent Care (including pregnancies Yes

Women & Children Clinical Documents : Gynaecology CPWC190 Gestational Trophoblastic Disease; Diagnosis and

Management of Yes

Women & Children Clinical Documents : Gynaecology CPWC197 Laparoscopic hysterectomy on a 23 hour ward Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC025 Down's Syndrome, Trisomy 13 & 18 Screening in

Pennine Acute Maternity Services Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC031 Stop Smoking Guideline & Care Pathway for

Maternity Services Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC039 Pregnant Women who are using Drugs &/or Alcohol Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC042 Home Birth Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC051 Anti-D Prophylaxis in Pregnancy & Following Birth Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC070 Early Gestational Sac (EGS) Pregnancy of

Unknown Location (PUL) and Suspected / Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC072 Antenatal Screening & Management of Results Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC074 Antenatal Care Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC083 Maternity management of women with a raised

Body Mass Index. Guideline for, Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC127 Antenatal & Postnatal Mental Health Pathway Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC131 Bladder Care; Intrapartum & Post Partum Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC139 Small for Gestational Age Singleton Pregnancy;

Investigations and Management of Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC147 Reduced Fetal Movements Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC156 HIV in Pregnancy Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC157 Amniocentesis Guideline Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC159 Genital Tract Sepsis in Obstetrics; Management of Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC160 Young Pregnant Women, Care Pathway for Yes





Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC169 Syphilis in Pregnancy and the Neonatal Period;

Management of Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC180 Maternity Care Pathway & Operational Policy Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC187 Cervical Cerclage; Insertion of Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal CPWC204 Diabetes; Management of Pregnant Women with

Type 1 and Type 2 Diabetes Yes

Women & Children

Clinical Documents : Maternity Services : Antenatal DPWC007 MEWS - Standards for maternal observations in

practice (including maternity early warning score & Yes

Women & Children

Clinical Documents : Maternity Services : Birth Centre CPWC128 Birth Centre Operational Guidelines: Pennine Acute

Trust Yes

Women & Children

Clinical Documents : Maternity Services : Fetal Loss/Death

EXWC001 Part 1

Stillbirth: Intrauterine Fetal Death > or = 24+0 weeks gestation (Greater Manchester, Lancashire N/A

Women & Children


EXWC001 Part 2

Stillbirth; (Greater Manchester, Lancashire & South Cumbria Strategic Clinical Networks) N/A

Women & Children


EXWC002 Part 1

Pregnancy Loss: North West Second Trimester Pregnancy Loss ICP N/A

Women & Children


EXWC002 Part 2

Pregnancy Loss: North West Second Trimester Pregnancy Loss Guideline N/A

Women & Children

Clinical Documents : Maternity Services : Labour CPWC029 Vaginal Birth After Caesarean Section Yes

Women & Children

Clinical Documents : Maternity Services : Labour CPWC040 Fetal Monitoring in Labour including Fetal Blood

Sampling Yes

Women & Children

Clinical Documents : Maternity Services : Labour CPWC043 Perineal Suturing Including 3rd & 4th Degree Tears Yes

Women & Children

Clinical Documents : Maternity Services : Labour CPWC049 Assisted Vaginal Delivery Yes

Women & Children

Clinical Documents : Maternity Services : Labour CPWC052 Labour & Birth Yes

Women & Children

Clinical Documents : Maternity Services : Labour CPWC061 Birthing Pool During Labour & Delivery; Use of the Yes

Women & Children

Clinical Documents : Maternity Services : Labour CPWC063 Multiple Pregnancy & Birth; Management of Yes

Women & Children

Clinical Documents : Maternity Services : Labour CPWC066 Induction and Augmentation of Labour Yes

Women & Children

Clinical Documents : Maternity Services : Labour CPWC071 Group B Streptococcus in Pregnancy & Labour;

Management of Yes

Women & Children

Clinical Documents : Maternity Services : Labour CPWC073 Pre labour Rupture of Membranes at Term;

Management of women with Yes

Women & Children

Clinical Documents : Maternity Services : Labour CPWC084 Preterm Labour & Extremely Preterm Labour &

Birth, including preterm Prelabour rupture of Yes

Women & Children

Clinical Documents : Maternity Services : Labour CPWC136 Meconium Stained Liquor Antenatally & in Labour;

Management of Yes

Women & Children

Clinical Documents : Maternity Services : LSCS & Obstetric CPWC027 Referral to Anaesthetist in Pregnancy Yes

Women & Children

Clinical Documents : Maternity Services : LSCS & Obstetric Anaesthesia

CPWC085 Caesarean Section Yes

Women & Children

Clinical Documents : Maternity Services : LSCS & Obstetric CPWC106 Thromboprophylaxis in Obstetrics Yes

Women & Children

Clinical Documents : Maternity Services : LSCS & Obstetric CPWC133 Epidural Analgesia in Labour including the

management of dural tap Yes

Women & Children

Clinical Documents : Maternity Services : Medicines CPWC130 Midwives Exemption List; Yes

Women & Children

Clinical Documents : Maternity Services : Medicines CPWC137 Remifentanil Patient Controlled Analgesia (PCA)

during labour; Use of Yes

Women & Children

Clinical Documents : Maternity Services : Obstetric Emergencies CPWC044 Primary Postpartum Haemorrhage; Management of Yes

Women & Children

Clinical Documents : Maternity Services : Obstetric Emergencies CPWC064 Placenta Praevia and Suspected Placenta Accreta;

Management of Yes

Women & Children

Clinical Documents : Maternity Services : Obstetric Emergencies CPWC090 Severe Pre-Eclampsia and Eclampsia; In-patient

Management of Yes

Women & Children

Clinical Documents : Maternity Services : Obstetric Emergencies CPWC091 Antepartum Haemorrhage not including Placenta

Praevia; Management of Yes

Women & Children

Clinical Documents : Maternity Services : Obstetric Emergencies CPWC092 Shoulder Dystocia Yes





Women & Children

Clinical Documents : Maternity Services : Obstetric Emergencies CPWC134 Breech Presentation including External Cephalic

Version Yes

Women & Children

Clinical Documents : Maternity Services : Obstetric Emergencies CPWC140 Cord Prolapse; Management of Yes

Women & Children

Clinical Documents : Maternity Services : Obstetric Emergencies EXWC003 Primary Postpartum Haemorrhage; NMGH only Yes

Women & Children

Clinical Documents : Maternity Services : Obstetric Medical Conditions

CPWC030 Epilepsy; Management of pregnancy & puerperium in women with Yes

Women & Children

Clinical Documents : Maternity Services : Obstetric Medical CPWC041 Haemoglobinopathy Screening Yes

Women & Children

Clinical Documents : Maternity Services : Obstetric Medical CPWC060 Cholestasis; Management of Obstetric Yes

Women & Children

Clinical Documents : Maternity Services : Obstetric Medical Conditions

CPWC062 Thromboembolic Disease in Pregnancy & the Puerperium: Acute Management of Yes

Women & Children

Clinical Documents : Maternity Services : Obstetric Medical CPWC107 Gestational Diabetes; Management of Yes

Women & Children

Clinical Documents : Maternity Services : Obstetric Medical CPWC150 Thrombocytopenia in Pregnancy Yes

Women & Children

Clinical Documents : Maternity Services : Obstetric Medical CPWC161 Hypertensive Disorders in Antenatal Day Unit;

Management of Yes

Women & Children

Clinical Documents : Maternity Services : Operational CPWC055 Maternal Death; Guideline for Practitioners in the

Event of a Yes

Women & Children

Clinical Documents : Maternity Services : Operational CPWC179

Women from 16+o weeks pregnant to 28 days postnatal presenting at the Emergency Department or Urgent Care Centre; Management of

Yes

Women & Children

Clinical Documents : Maternity Services : Operational DPWC006 Infant Abduction; Suspected or Actual Yes

Women & Children

Clinical Documents : Maternity Services : Operational DPWC012 Education and Training in Maternity Services;

Standards for Yes

Women & Children

Clinical Documents : Maternity Services : Operational DPWC013

Safe Staffing Levels & the Responsibilities of Consultant Obstetricians on Labour Ward; Governing

Yes

Women & Children

Clinical Documents : Maternity Services : Operational DPWC017 Maternity Escalation, Divert & Closure Yes

Women & Children

Clinical Documents : Maternity Services : Postnatal Care/Neonatal Care

CPWC038 Weighing Babies whilst in Midwifery Care Yes

Women & Children


CPWC048 Formula Milk Feeding; Guideline for Yes

Women & Children


CPWC053 Breast Feeding Yes

Women & Children


CPWC065 Candida Albicans (Thrush) in the Breastfeeding Mother & her Baby; Management of Yes

Women & Children


CPWC089 Co-Sleeping & Parent and Infant Bed-Sharing Yes

Women & Children


CPWC094 Hepatitis B and Hepatitis C; management of positive screen in Mothers and babies Yes

Women & Children


CPWC108 Postnatal Care Yes

Women & Children


CPWC109 Tongue Tie in Neonates (Frenulotomy); Division of Yes

Women & Children


CPWC110 Newborn (ENB); Performing the Physical Examination of the Yes

Women & Children

Clinical Documents : Maternity Services : Postnatal CPWC126 Newborn Bloodspot Yes

Women & Children

Clinical Documents : Maternity Services : Postnatal CPWC138 Newborn Infant; Immediate Routine Care of the

Term Yes





Women & Children

Clinical Documents : Maternity Services : Postnatal CPWC162 Cup Feeding the Neonate Yes

Women & Children

Clinical Documents : Maternity Services : Postnatal CPWC201 Investigation of babies of mothers with thyroid

disease Yes

Women & Children

Clinical Documents : Maternity Services : Transfer CPWC087 Maternity Outliers Yes

Women & Children

Clinical Documents : Maternity Services : Transfer DPWC004 Transfer & Handover of Care Between

Professionals in the Maternity Services Yes

Women & Children

Clinical Documents : Medicine Management EDT016 Antibiotic (Paediatrics) N/A

Women & Children Clinical Documents : Neonatal CPDI026 Blood and Blood Components on the Neonatal Unit;

Use of Yes

Women & Children Clinical Documents : Neonatal CPWC003 Neonates at Risk of Hypoglycaemia or with

Neonatal Hypoglycaemia; Management of Yes

Women & Clinical Documents : Neonatal CPWC014 Neonatal Injuries; Management of YesWomen & Children Clinical Documents : Neonatal CPWC032 Neonatal Stabilisation & Transfer Yes

Women & Children Clinical Documents : Neonatal CPWC034 Neonatal Abstinence Syndrome; Management of

the Infant of a Mother who has misused substances Yes

Women & Children Clinical Documents : Neonatal CPWC067 Golden Hour - Resuscitation & Early Care of

Preterm Infants 29+0 Weeks Gestation & Below Yes

Women & Children Clinical Documents : Neonatal CPWC086 Attendance at Deliveries Yes

Women & Children Clinical Documents : Neonatal CPWC088 Neonatal Unit; Admission to Yes

Women & Children Clinical Documents : Neonatal CPWC111 Low Cord Ph in a Term Neonate; Management of Yes

Women & Children Clinical Documents : Neonatal CPWC145 Neonatal Jaundice; Management of Yes

Women & Children Clinical Documents : Neonatal CPWC148 Intravenous Fluids & Medicines in the Neonate;

Commencement, Maintenance, & Removal of Yes

Women & Children Clinical Documents : Neonatal CPWC168 HIV, Hepatitis B, Hepatitis C in Pregnancy - Care of

the Baby Yes

Women & Children Clinical Documents : Neonatal CPWC175 Therapeutic Hypothermia for Neonatal Hypoxic

Ischaemic Encephalopathy (HIE) Yes

Women & Children Clinical Documents : Neonatal CPWC176 Inhaled Nitric Oxide for Persistent Pulmonary

Hypertension of the Newborn; use of Yes

Women & Children Clinical Documents : Neonatal CPWC181 Neonatal Cannulation & Venepuncture Yes

Women & Children Clinical Documents : Neonatal CPWC183 Very Low Birth Weight Infant; Feeding Yes

Women & Children Clinical Documents : Neonatal CPWC184 High flow nasal cannula (HFNC) for respiratory

support (Optiflow® or Vapotherm Precision Flow®) Yes

Women & Clinical Documents : Neonatal CPWC188 Parenteral Nutrition on the Neonatal Unit; Use of YesWomen & Children Clinical Documents : Neonatal CPWC189 Fluconazole prophylaxis to Prevent Systemic

Fungal Infections in Extremely Low Birth Weight Yes

Women & Children Clinical Documents : Neonatal CPWC191 Umbilical Line Insertion Yes

Women & Children Clinical Documents : Neonatal CPWC193 Neonatal Cranial Ultrasound; Screening Yes

Women & Children Clinical Documents : Neonatal CPWC198 Neonate; Exchange Transfusion in Yes

Women & Children Clinical Documents : Neonatal CPWC199 Sepsis; Management of Asymptomatic Neonates at

risk of Early Onset Sepsis Yes

Women & Children Clinical Documents : Neonatal CPWC202 Gastro-oesophageal reflux in Neonates and

Preterm infants Yes

Women & Clinical Documents : Neonatal CPWC205 Neonatal Death; Management of Yes

Women & Children Clinical Documents : Neonatal CPWC211 Oxygen administration on Neonatal Unit Yes

Women & Children Clinical Documents : Neonatal DPWC015 Neonatal Doses Yes

Women & Children Clinical Documents : Neonatal EDT024 Neonatal Unit Antibiotics Yes

Women & Children Clinical Documents : Paediatrics CPWC002 Sucrose (Paediatric) Yes





Women & Children Clinical Documents : Paediatrics CPWC012 Sedation (Paediatric) Yes

Women & Children Clinical Documents : Paediatrics CPWC017 Palivizumab (Paediatric) Yes

Women & Children Clinical Documents : Paediatrics CPWC023 CPAP (Paediatric) Yes

Women & Children Clinical Documents : Paediatrics CPWC033 Transfer (Paediatric) Yes

Women & Children Clinical Documents : Paediatrics CPWC035 MANCHEWS (Paediatric) Yes

Women & Children Clinical Documents : Paediatrics CPWC045 Post-Op (Paediatric) Yes

Women & Children Clinical Documents : Paediatrics CPWC068 Diabetes - Ketoacidosis (Paediatric) Yes

Women & Children Clinical Documents : Paediatrics CPWC069 Mental Health (Paediatric) Yes

Women & Children Clinical Documents : Paediatrics CPWC078 Diabetes - new diagnosis (Paediatrics) Yes

Women & Children Clinical Documents : Paediatrics CPWC079 Diabetes fasting or Surgery (Paediatric) Yes

Women & Children Clinical Documents : Paediatrics CPWC081 Diabetes - Hypoglycaemia (Paediatrics) Yes

Women & Children Clinical Documents : Paediatrics CPWC152 NG Tube (Paediatric & Neonatal) Yes

Women & Children Clinical Documents : Paediatrics CPWC195 Paediatric Diabetes Operational Policy Yes

Women & Children Clinical Documents : Paediatrics CPWC206 Sepsis (Paediatrics) Recognition & Management of

suspected Yes

Women & Children

Clinical Documents : Patient Group Directions : Women and Children's

PGD072 PGD072 Ranitidine in Labour N/A

Women & Children


PGD098 PGD098 Insertion of Mirena Intrauterine System (Levonorgestrel IUS) N/A

Women & Children


PGD137 PGD137 Local Anaesthetic Cream (Paediatric) N/A

Women & Children


PGD146 PGD146 Misoprostol for postpartum haemorrhage & uterine atony N/A

Women & Children


PGD147PGD147 Etonogestrel 68mg subdermal implant – Nexplanon ® Subdermal Contraceptive Implant postnatal contraception for teenagers

N/A

Women & Children


PGD148 PGD148 Cabergoline following fetal loss, stillbirth or neonatal death N/A

Women & Children


PGD149PGD149 for routine antibiotic prophylaxis against Group B Streptococcus (GBS) for GBS positive women in labour

N/A

Women & Children


PGD155 PGD155 Pre Operative Ranitidine in Maternity N/A





Women & Children


PGD157PGD157 Prostaglandin slow release PGE2 Pessary (PROPESS) 10mg or Dinoprostone (Prostin E2) 3mg tablet for the induction of low risk, post term

N/A

Women & Children


PGD224 PGD224 Codeine Phosphate for Pain Relief in Early Labour N/A

Women & Children


PGD242 PGD242 for the Supply & Administration of Inactivated Influenza Vaccine to Pregnant Women N/A

Women & Children


PGD246 PGD246 Local Anaesthetic for use in Colposcopy/Hysteroscopy procedures N/A

Women & Children


PGD306 PGD 306 Ibuprofen 400mg tablets for Gynae pain, Administration of N/A

Women & Children


PGD307 PGD307 Administration of Co-dydramol 10/500mg tabs for Gynae related pain N/A

Workforce Clinical Documents : Patient Group Directions : Occupational PGD248 PGD248 Supply of Chlorhexidine (Hibiscrub) Skin

Cleanser N/A

Workforce Clinical Documents : Patient Group Directions : Occupational PGD292 PGD292 Administration of Bexero Meningococcal

Group B vaccine (POM) N/A

WorkforceClinical Documents : Patient Group Directions : Occupational Health

PGD297 PGD297 Administration of Typhoid Vaccine – Typhim Vi (POM) N/A

Workforce Non Clinical Documents : Finance EDF008 Travel Expenses (AFC Staff Only); Payment of Yes

Workforce Non Clinical Documents : General Trust Policies EDE038 Mobile Phone Yes

Workforce Non Clinical Documents : General Trust Policies EDE039 Mobile Phone Procurement including

Telecommunication Devices Yes

Workforce Non Clinical Documents : General Trust Policies EDG001 Police Disclosure of Information & Clinical Samples Yes

Workforce Non Clinical Documents : General Trust Policies EDH013 Whistleblowing Yes

Workforce Non Clinical Documents : IM&T Documents EDI001 Information Governance Yes

Workforce Non Clinical Documents : IM&T Documents EDI006 Barcoding Yes

Workforce Non Clinical Documents : IM&T Documents EDI007 Barcodes – Deployment and Use Yes

Workforce Non Clinical Documents : IM&T Documents EDI016 Information and Data Quality Assurance Policy Yes

Workforce Non Clinical Documents : IM&T Documents EDI017 Information and Data Quality Assurance Strategy Yes

Workforce Non Clinical Documents : IM&T Documents EDI018 Information Management & Technology 2015 -

2018 Yes

WorkforceNon Clinical Documents : Workforce & OD : Equality & Human Rights

EDH041 Equality & Human Rights Strategy Yes






EDH062 Equality Impact Assessment Yes


EDH081 Accessible Information & Communication for Service Users Yes

WorkforceNon Clinical Documents : Workforce & OD : Human Resources

EDH002 Conduct and Disciplinary Yes


EDH003 Grievance Policy & procedure Yes

Workforce Non Clinical Documents : Workforce & OD : Human EDH004 Equal Opportunities in Employment Yes


EDH005 Dignity at Work Yes


EDH007Organisational Change; (incorporating Redeployment Guidance, Protection of Pay & Conditions of Service & Redundancy)

Yes


EDH009 JLNC Constitution Yes


EDH010 Handling Concerns about Medical Staff Policy (Ill Health, Capability, Conduct and Remediation) Yes


EDH012 Absence - Career Grade Medical & Dental Staff Yes


EDH014Maternity, Paternity & Adoption Leave (Incorporating the Administrative Guidelines & the Breast Feeding at Work Guidelines)

Yes


EDH018

Partnership Working Agreement including Trade Union Recognition, Time off for Trade Union Duties & Activities and Facilities for Trade Union Representatives

Yes


EDH027 Attendance Management Yes


EDH028 Special Leave Yes


EDH030 Holiday Leave Yes


EDH031 Capability Yes


EDH039 Disclosure & Barring Service (previously CRB) Yes


EDH040 Recruitment; International Yes


EDH042 Temporary Staff (Including Locum Doctors/Consultants); Use of No


EDH046 Recruitment Code of Practice Yes


EDH047 Retirement Yes


EDH049 Job Banding Yes






EDH050 Flexible Working/Work Life Balance Yes


EDH052 Alcohol, Drug & Other Substance Misuse at Work Yes


EDH055 Conduct & Disciplinary Procedure Guideline Yes


EDH056 Leavers Process: Managers Guidance Yes


EDH061Job Plan Mediation and Appeals Policy and Procedure for Consultants, SAS Doctors and Dentists

Yes


EDH063 Capability Procedure Yes


EDH065 Inclement Weather/Major disruption to travel links Yes


EDH066 Transfer of Undertakings (Protection of Employment) Yes


EDH071 Agency Worker Regulations - Guidance for Managers Yes


EDH073 Revalidation & Appraisal for Non-Trainee Medical Staff Yes


EDH077 European Working Time Directive compliance; reporting & monitoring on Yes


EDH078 Shared Parental Leave Policy Yes


EDI008 Registrations Authority Operating Procedures Yes


MCH HR008 Equal Opportunities (Community Services North) N/A


MCH HR011 Job Share (Community Services North) N/A


MCH HR017 Term Time & Annualised Hours (Community Services North) N/A


MCH HR018 Toil/Flexitime (Community Services North) N/A


MCH NO REF Professional Registration (Community Services North) N/A

Workforce Non Clinical Documents : Workforce & OD : Learning & OD CPDI082 Intravenous Medicines; Training & Assessment

Requirements for Staff Preparing & Administering Yes

Workforce Non Clinical Documents : Workforce & OD : Learning & OD EDH016 Training Events; Learning & Organisational

Development Policy for Application & Attendance at Yes

Workforce Non Clinical Documents : Workforce & OD : Learning & OD EDH021 Moving and Handling Yes

Workforce Non Clinical Documents : Workforce & OD : Learning & OD EDH024 Induction and Mandatory Training Yes

Workforce Non Clinical Documents : Workforce & OD : Learning & OD EDH032 Bariatric Yes





Workforce Non Clinical Documents : Workforce & OD : Learning & OD EDH054 Learning & Assessment in Practice; Standards to

Support Yes

Workforce Non Clinical Documents : Workforce & OD : Learning & OD EDH067 Appraisal; Values based appraisal & personal

development review Yes

Workforce Non Clinical Documents : Workforce & OD : Learning & OD EDH069 Learning & Organisational Development Quality

Assurance Yes

Workforce Non Clinical Documents : Workforce & OD : Occupational CPDI018 Needlesticks, Sharps, Accidental Inoculation Yes

WorkforceNon Clinical Documents : Workforce & OD : Occupational Health

CPDI071 Tuberculosis; Staff Yes


EDC001 Hepatitis B and C in the Health Care Worker Yes


EDH034 Staff Immunisation and Vaccination Yes


EDH080 Workplace Physical Activity Guidelines Yes


PGD166 PGD166 Administration of Hepatitis A Vaccine N/A


PGD167 PGD167 Administration of Diphtheria/Tetanus/Polio vaccine N/A


PGD168 PGD168 Administration of BCG vaccine N/A


PGD170 PGD170 Supply of Chlorhexidine Gluconate Mouthwash N/A


PGD172 PGD172 Administration of Varicella Zoster (VZ) vaccine N/A


PGD173PGD173 Best Practice Guide for administration of Tuberculin Purified Protein Derivative (PPD) BP 2 TU per 0.1ml

N/A


PGD174PGD174 Best Practice for the administration and supply of Truvada and Raltegravir tablets for HIV post exposure prophylaxis

N/A


PGD175 PGD175 Supply of Naseptin Nasal Ointment N/A


PGD176 PGD176 Supply of Mupirocin Nasal Ointment N/A


PGD177 PGD177 Administration of Measles/Mumps & Rubella (MMR) Vaccine N/A

Workforce Non Clinical Documents : Workforce & OD : Occupational PGD179 PGD179 Administration of Hepatitis B vaccine N/A


PGD245 PGD245 for the Administration of Influenza Vaccine N/A