Policy Library

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Policies and supporting documents are listed in alphabetical order on this page. To help find what you're looking for:

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Please note: Certain links within the policy documents will navigate to related content or documents hosted on the WA health system intranet. As a result, these links may not be accessible when using a public web browser. If you need further assistance locating a policy document, please contact the WACHS Policy Unit.

A

Aboriginal Mental Health Consultation Guideline
Guideline to enable culturally safe practice for Aboriginal consumers and their carers in outpatient and inpatient settings.
Aboriginal Mental Health Consultation Procedure - Great Southern Mental Health Service
This Procedure applies only to the site named here
Aboriginal Mental Health Consultation Procedure - Wheatbelt Mental Health Service
The WA Country Health Service (WACHS) Wheatbelt Mental Health (WMHS) is a specialist service that provides inpatient and ambulatory care to mental health patients in the Wheatbelt Mental Health Catchment Area. The service is committed to working to reduce barriers to mental health services and actively engage consumers likely to fall 'through the gaps'. People of Aboriginal 1 descent and their families are considered to form part of this group. State and National practice standards require that services deliver treatment and support in a manner which is sensitive to the cultural beliefs, values, practices and language needs of Aboriginal consumers, their family, carers and community.
Absent Without Leave and Missing Persons Flowchart - Broome Mental Health Unit
Flowchart for absent without leave and missing persons.
Absent Without Leave and Missing Persons Procedure - Broome Mental Health Unit
The Broome Mental Health Inpatient Unit aims to provide for the safety and wellbeing of all inpatients.
Access and Admission Criteria for Adult Older-Adult Community Mental Health Services Policy
The purpose of this policy is to inform and guide staff in assessing and admitting to the Community Mental Health Service. All referrals accepted into the service for assessment and/ or treatment must be in accordance with this policy.
Access Control Procedure
As part of the its security risk management process, WACHS, in consultation with employees, ensures that all reasonably foreseeable security risks associated with access to workplaces are identified, assessed and eliminated where reasonably practicable, or the risks associated with access to workplaces are effectively controlled.
Access to Clinical Supervision Procedure - Wheatbelt Mental Health Service
The Wheatbelt Mental Health Service is committed to providing staff with high quality clinical supervision.
Access to External Clinical Supervision Procedure - Great Southern Mental Health Service
This procedure sets out the criteria and approval process for GSMHS clinical to access external clinical supervision.
Accessing Medications After-Hours Procedure - Busselton Health Campus
This procedure outlines the process that the Busselton Health Campus After Hours Hospital Coordinators must follow to obtain medications for patients when the Pharmacy is not open.
Accessing Medications from the WACHS-SW Pharmacy, located at Bunbury Hospital - Outside of Pharmacy Hours Procedure
This procedure outlines the process that Bunbury Hospital After Hours Hospital Coordinators (HCAH) must follow to obtain medications for patients when the pharmacy is not open.
Acute Psychiatric Unit Clinical Handover Procedure
This procedure outlines how WACHS Mental Health Inpatient Units ensure effective and safe handover between nursing shifts and between members of the Mental Health Multidisciplinary Team providing care. Mental health consumers are to be active participants in handover. The ISoBAR structure underpins all clinical handover in WACHS. This procedure does not address intrahospital or interhospital clinical handover.
Acute Response in Child and Adolescent Mental Health Service Policy
All WACHS health services are required to provide an acute response based on consumer needs. CAMHS will provide an acute response to the various levels as outlined in this policy, in collaboration with the Emergency Departments where appropriate, and with support from the Community Mental Health Team.
Acute Stroke Clinical Standards and Guidelines - EUCP Policy
The WA Country Health Service (WACHS) endorses the National Stroke Foundation Clinical Guidelines for Stroke Management 2017, Acute Stroke Clinical Care Standard 2015 and the WA Protocol for Intravenous Thrombolysis in Acute Ischaemic stroke - 2018 as evidence based recommended practice for use by WACHS Medical, Nursing and Allied Health staff.
Additional EUCP Resources Guideline
WACHS has endorsed these additional resources for use in clinical practice.
Additional Observations of Patients at Risk of Harm Procedure - Acute PsychiatricUnit
This procedure aims to provide information on the use of additional observations for patients at risk of harm to themselves or others, or harm from others on the APU.
Adjusting Your Seat - Information Sheet
Includes information about correct seat height, tilt, back rest height and angle, arm rests and foot rests.
Administration of Alcohol Brief Intervention Flowchart
Flowchart outlining the Alcohol Brief Intervention process.
Administration of Donations Procedure - South West
The purpose of this document is to provide South West staff with guidance regarding the administration of donated funds and the criteria upon which donations will be accepted, and the manner in which donated funds can be expended.
Administration of Donations Procedure - Wheatbelt
The purpose of this document is to provide Wheatbelt staff with guidance regarding the administration of donated funds and the criteria upon which donations are to be accepted, and the manner in which donated funds can be expended.
Administration of Fluoride Varnish by Non-Dental Practitioners Policy
Fluoride varnish is a valuable tool in the prevention of dental decay in both deciduous and permanent teeth. Traditionally, the application of fluoride varnish is only to be carried out by a dental practitioner, however the Schedules of the Standard for the Uniform Scheduling of Medicines and Poisons (SUSMP) allows preparations containing fluoride that would otherwise be Schedule 4 to be exempt from scheduling provided the approval of an appropriate authority has been given. This policy sets out the training and competency in fluoride varnish application that is required to enable approved health professionals to apply fluoride varnish.
Administration of the Alcohol and Tobacco Screening Tool and Brief Intervention Procedure
This procedure underpins the WACHS Alcohol and Tobacco Brief Intervention Policy and describes the WACHS procedure for the administration of the Alcohol and Tobacco Screening Tool and Brief Intervention.
Administration of Thiamine in Chronic Alcohol Abuse Guideline - Albany Health Campus
Poor recognition and inappropriate treatment of thiamine deficiency, for which chronic alcohol abuse is the most common cause in Australia, can result in significant morbidity and mortality secondary to Wernike-Korsakoff Syndrome. This document provides clear guidelines for the administration of thiamine in patients with a known or suspected history of chronic alcohol abuse, with the aim to prevent and treat Wernike-Korsakoff Syndrome.
Admission of Mental Health Patients Procedure - Albany Hospital Acute Psychiatric Unit
This procedure refers to those patients admitted to the Albany Hospital under the care of a psychiatrist. Unless specifically stated, there is no distinction according to physical location within the region, location within the hospital, or legal status of patients.
Admission to Goldfields Mental Health Inpatient Service Procedure - Kalgoorlie Hospital Mental Health Inpatient Unit
The Goldfields Mental Health Inpatient Service (GMHIS) provides assessment, care and treatment for people experiencing acute symptoms and/or behavioural change due to mental illness or psychiatric crises that cannot be managed in the community. Patients accessing psychiatric inpatient treatment do so on the basis that care and treatment is provided in the least restrictive manner possible, consistent with the Mental Health Act 2014 (WA) [MHA] and with regard to the safety of patients, staff, carers, visitors and the general public.
Admission to Goldfields Mental Health Service - Community Mental Health Procedure
GCMHS prioritises resources for those who meet the eligibility criteria as per WACHS Admission Criteria for Adult/Older Adult Community Mental Health Services Policy and Child and Adolescent Mental Health Services Access Criteria Policy.
Admission to High Dependency Unit Procedure - Broome Mental Health Inpatient Unit
The High Dependency Unit is located within the Broome Mental Health Inpatient Unit (BMHU). It provides short term intensive interventions for patients in a low stimulus environment.
Admission to the Kalgoorlie Health Campus Procedure
The purpose of this procedure is to ensure the admission of patients process meets the needs of each patient through the provision of quality care in a safe environment and meeting the organisation's needs through the efficient use of health service resources.
Admission, Discharge and Intra-hospital Transfer Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management of admission, discharge, and intra-hospital transfer of patients throughout the WA Country Health Service. (The policy also incorporates the content of the WA Health Statewide Discharge Summary Policy MP 0016/16 which was rescinded 29 September 2017.)
Adult Airway Management Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care of Adult Airway Management throughout the WA Country Health Service. The CPS does not include specific procedural airway management information for the community setting.
Adult Diabetic Ketoacidosis (DKA) Guideline - South West
This guideline describes the management of patients who present to a WA Country Health Service (WACHS) South West (SW) hospital with diabetic ketoacidosis (DKA).
Adult Dysphagia Screening and Assessment Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management of dysphagia screening and assessment throughout the WA Country Health Service (WACHS).
Adult Patients Requiring Stimulant Medication Procedure
The Schedule 8 Medicines Prescribing Code (Department of Health August 2017) set out requirements for the authorisation, prescription and treatment of patients requiring stimulant medication.
Adult Psychiatric Inpatient Services - Referral Admission Assessment Care Treatment Discharge Policy
The purpose of this policy is to: - Guide appropriate referral and admission to adult inpatient mental health services within the WA Country Health Service (WACHS) - Promote evidenced based practice in the assessment, care, treatment and management of mental health patients who are admitted to adult inpatient services within WACHS.
Adult Refeeding Syndrome Clinical Guideline
The purpose of this guideline is to establish minimum practice standards for the care and management of refeeding syndrome in adults throughout the WA Country Health Service (WACHS).
Adults with Impaired Decision Making Capacity Procedure
The purpose of this procedure is to ensure a consistent approach throughout the WA Country Health Service (WACHS) for managing decisions making where an adult (a person over 18 years) has impaired decision making capacity. It prescribes the steps to be taken where an adult has impaired decision making capacity in cases where an application to the State Administrative Tribunal (SAT) is required to protect the best interests of the person.
Advance Health Directive and Enduring Power of Guardianship Guideline
State legislation introduced in February 2010, provides instruments (Advance Health Directive or Enduring Power of Guardianship) for people to plan in advance for circumstances when they may become unable to make decisions for themselves.
Advisory Council Participation Payments, Reimbursement of Expenses and Support Policy
This policy applies only to formally appointed community and consumer representatives of District Health Advisory Councils (DHACs), and the Wheatbelt and Great Southern Aboriginal Health Advisory Councils, NOT to other WACHS advisory or committee members.
After Hours Access to Pharmacy Procedure - Kimberley
All requirements for pharmacy medicines are to be met during normal pharmacy operating hours. In the absence of a pharmacy on-call service, after hours nurse managers are granted access to the pharmacy after hours to access essential or emergency items only. Routine (i.e. non-urgent) requirements must be fulfilled the following day or next working day during normal pharmacy operating hours. All entries into pharmacy after hours will be recorded through the swipe card system and compared to documented issues.
After Hours Remote Clinic Call Out Procedure
This procedure oultines the process for after hours call outs for the One Arm Point, Lombadina, Looma, Warmun and Kalumburu Clinics which are designated remote area nursing posts that provide primary health care and emergency care service during business hours.
After Hours Visitor Access Procedure - Busselton Health Campus
This procedure sets out how visitor access is controlled to ensure a secure environment is maintained at the Busselton Health Campus after hours.
Aged Care Accreditation Standard 1.4 Comments and Complaints Flowchart
This aged care services flowchart sets out how all complaints are now to be referred to the new the new Aged Care Quality and Safety Commission.
Aged Care Accreditation Standard 2.10 Nutrition and Hydration Flowchart
Aged Care Nutrition and Hydration Flowchart
Aged Care Accreditation Standard 2.11 Skin Care Flowchart
WACHS Residential Aged Care Flowchart
Aged Care Accreditation Standard 2.12 Continence Management Flowchart
WACHS Residential Aged Care Flowchart
Aged Care Accreditation Standard 2.13 Behaviour Management Flowchart
WACHS Residential Aged Care Flowchart
Aged Care Accreditation Standard 2.14 Mobility and Dexterity Flowchart
WACHS Residential Aged Care Flowchart
Aged Care Accreditation Standard 2.15 Oral and Dental Care Flowchart
WACHS Residential Aged Care Flowchart
Aged Care Accreditation Standard 2.16 Sensory Loss Flowchart
WACHS Residential Aged Care Flowchart
Aged Care Accreditation Standard 2.17 Sleep Flowchart
WACHS Residential Aged Care Flowchart
Aged Care Accreditation Standard 2.7 Medication Management Flowchart
WACHS Residential Aged Care Flowchart
Aged Care Accreditation Standard 2.8 Pain Flowchart
WACHS Residential Aged Care Flowchart
Aged Care Accreditation Standard 2.9 Palliative Care Flowchart
WACHS Residential Aged Care Flowchart
Aged Care Accreditation Standard 3.4, 3.5 and 3.6 Resident Lifestyle Flowchart
WACHS Residential Aged Care Flowchart
Aged Care Accreditation Standard 3.7, 3.8, 3.9 and 3.10 Resident Lifestyle Flowchart
WACHS Residential Aged Care Flowchart
Aged Care Criminal Record Screening Policy
This policy aims to ensure greater security and protection for older people receiving Australian Government subsidised aged care services. Note: The policy continues to apply and will be incorporated into the revised WA Health CRS policy in due course.
Aged Care CRS Decision to Employ Form
The Regional Director and the Director Human Resource Services are required to complete and co-sign this form.
Aged Care CRS Decision to Engage Form
This form relates to WACHS Aged Care Criminal Record Screening Policy.
Aged Care CRS Request form - Volunteer
This form relates to WACHS Aged Care Criminal Records Policy.
Aged Care CRS Statutory Declaration
This declaration relates to WACHS Aged Care Criminal Record Screening Policy.
Airway Suctioning Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management of airway suctioning throughout the WA Country Health Service (WACHS). Removing unwanted variation in clinical practice and following best practice guidelines has been found to reduce inappropriate care (overuse, misuse and underuse) thus improving health outcomes, reducing preventable harm and decreasing wastage.
Albany Team Midwifery Antenatal Care Procedure - Albany Hospital
This procedure sets out how Team midwifery care is provided at Albany. It refers to care given during pregnancy, childbirth and the early postpartum period by a small team of hospital midwives in collaboration with participating GPOs. Birthing is supported within the hospital labour ward. The philosophy being continuity of care rather than individual caregivers, and to promote the normality of childbirth by providing consistent psychosocial support.
Alcohol and Tobacco Brief Intervention Policy
The WA Country Health Service will undertake Brief Intervention including assessment, feedback and referral relating to the alcohol and tobacco use with relevant patients. The aim is to reduce harm caused by alcohol and tobacco, and to provide supportive and non-judgemental care.
Alcohol, Tobacco and Other Drugs Clinical Practice Standard
This CPS has been endorsed for use by WACHS and should be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.
Alerts and Notification of Clinical Risk Procedure - Great Southern Mental Health Service
The objective of this procedure is to reduce the risk of an adverse event related to an identified risk by improving communication of these risks when engaging with consumers.
Allied Health Assistants Policy
This policy applies to employees of WACHS engaged as AHAs and the AHP that delegates to and monitors tasks of AHAs. The intent of this policy also applies to service partnerships where WACHS AHPs delegate and monitor activities of an AHA employed by other organisations.
Allied Health Clinical Handover Policy
The aim of this policy is to ensure WACHS allied health clinical handover achieves effective, high quality communication of relevant clinical information when responsibility for patient care is transferred between facilities providing allied health services.
Allied Health Collaborative Arrangements with External Service Providers Guideline
This document aims to provide guidelines for collaborative allied health service arrangements between the WA Country Health Service and external allied health service providers in country Western Australia for all eligible, in-scope WACHS allied health services.
Allied Health Professional Supervision Policy
This policy aims to provide structure and clarity in regard to the implementation of allied health professional supervision within WACHS.
Allied Health Professionals Engaging in Outside Allied Health Employment Procedure
This procedure aims to assist allied health professionals, and their relevant managers, to ensure compliance with organisational and professional codes of ethics and conduct, and awareness of and the appropriate management of, conflict of interest. The procedure includes a written agreement between the manager and employee which documents the conditions under which approval for outside allied health employment is granted.
Alternative Pathway for Stroke Flowchart - Wheatbelt
Alternative Pathway for Stroke Flowchart for the Wheatbelt region
Ambulance Booking for Emergency Transfer and Escalation Flowchart - Great Southern
This flowchart outlines the process for booking an ambulance for emergency transfer and escalation in the Great Southern
Anaesthetic Services, Pre-Operative Assessment and Investigations Guideline - Albany Hospital
This guideline is intended for use by the pre-assessment nurse, surgical team and anaesthetists as a reference for booking emergency cases for theatre, pre-operative assessment and investigations. Additional queries are to be directed to the responsible anaesthetists.
Anaphylaxis During Anaestheia - EUCP Policy
The WACHS endorses the Anaphylaxis Management Guidelines developed by the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) in conjunction with ANZCA, through the Anaesthetic Allergy Subcommittee of the Quality and Safety Committee as evidence based recommended practice for use by medical, nursing and midwifery staff. ANZAAG have developed an anaphylaxis box to aid with management of patients where perioperative anaphylaxis occurs. The box should be stored in an agreed location in operating theatres well known to staff.
Animals in Healthcare Settings Policy
This policy identifies, and reduces the risk associated with animal visits and residential pets in the health care facilities.
Antenatal and Postnatal Syphilis Screening for Outbreak Regions Guideline
This guideline is to assist practitioners in increasing the frequency and uptake of antenatal screening in areas of WA currently experiencing an outbreak or higher than usual rates of syphilis.
Antibiotic Prophylaxis - Surgical Guideline
Endorsed guidelines for antibiotic prophylaxis for patients in WACHS hospitals.
Antimicrobial Prescribing Procedure - South West
This procedure outlines the process that is to be utilised to prescribe an antimicrobial agent with WACHS-South West.
Antimicrobial Stewardship Management Program Procedure - Midwest
This document relates to the WACHS Midwest Antimicrobial Stewardship Management Program which aims to effect change in antimicrobial prescribing, reduce unnecessary antimicrobial use and promote the use of agents less likely to select resistant bacteria.
Antimicrobial Stewardship Policy
Antimicrobial stewardship (AMS) is a systematic approach to optimising use of antimicrobials to reduce inappropriate use, improve patient outcomes and reduce adverse consequences of antimicrobial use (including antimicrobial resistance, toxicity and unnecessary costs). This policy is intended to supplement the existing WACHS Medication Administration for Nurses, Midwives and Unregulated Health Workers Policy.
Antineoplastic Therapy Prescribing Using Fiona Stanley Hospital MR860 Charts Procedure
This procedure pertains to all antineoplastic therapy prescribed for the treatment of adults with cancer at the WACHS Regional Cancer Centres.
ANZCA Acute Pain Management - Scientific Evidence - EUCP Policy
The WACHS endorses the Australian and New Zealand College of Anaesthetists (ANZCA), Acute Pain Management: Scientific Evidence fourth edition 2015 as evidence based recommended practice for use by medical, nursing and midwifery staff.
Appendix 1 - Aged Care CRS Process
This process relates to WACHS Aged Care Criminal Record Screening Policy.
Application to Provide Visiting Chaplaincy Services Form - Albany Health Campus
In accordance with the WA Health Volunteers Policy all clergy and church affiliated volunteers who wish to visit patients in an official church capacity at the Albany Health Campus, is required to be formally approved by the health service to do so.
Approval to Publish Internet Content Flowchart
Process of approval to publish content via the internet.
Arterial Line Insertion - Transducing and Monitoring Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management of Arterial Line Insertion -Transducing and Monitoring - Clinical Practice Standard, throughout the WA Country Health Service (WACHS).
Assertive Follow Up and Welfare Check Procedure - Goldfields Mental Health Service
This procedure provides a guide to the process of checking the welfare of referred and existing patients, and the degree of assertiveness of such checks.
Assessment and Management of Environmental Ligature in General Wards Procedure - Great Southern
This Great Southern procedure outlines the management intervention for patients at risk of self-harm on a general ward is to ensure that the patient is adequately supervised and observed for the level of risk identified.
Assessment and Management of Interhospital Patient Transfers Policy
The purpose of this policy is to establish minimum practice standards for the assessment, care and management of the patient requiring interhospital transfer from a WACHS facility.
Assessment of Suitability for Birth Procedure - Bridgetown Hospital
All women planning to birth at Bridgetown Hospital are to be assessed against the defined exclusion criteria at the first and subsequent ante-natal visits.
Attending the Campus for a Same Day Short Stay Procedure (With or Without Admission) at Global Diagnostics Australia
This document outlines the process to be carried out for patients attending the campus for a same day or short stay procedure (with or without admission) at Global Diagnostics Australia.
Audit Policy
This policy provides the framework for the conduct of the WACHS audit function, which in accordance with the WACHS Internal Audit Charter, provides objective and independent assurance and advice over processes and systems of internal control and risk management to the Board, Audit and Risk Committee, the Chief Executive (CE) and to the Executive.
Australian Health Practitioner Regulation Agency (AHPRA) Mandatory Notification Procedure
The purpose of this procedure is to ensure that all staff are aware of their obligations in relation to mandatory notification to the Australian Health Practitioner Regulation Agency (AHPRA) and Chief Executive (CE).
Australian Injectable Drugs Handbook - EUCP Policy
WACHS has endorsed the Australian Injectable Drugs Handbook for use in clinical practice.
Autonomic Dysreflexia Resource for Health Service Providers EUCP Policy
The WACHS endorses the WA State Spinal Injury Unit Resource for Health Service Providers on Autonomic Dysreflexia as evidence based recommended practice for use by WACHS Medical, Nursing, Midwifery and Allied Health Staff.

B

BACPAC Mental State Assessment
Mental State Assessment tool - to be read in conjunction with the WACHS Assessment Admission Treatment and Discharge of Mental Health Patients in Emergency Departments and General Wards Policy.
BCP to Respond to an Acute Shortage of Psychiatric Medical Staff in Acute Psychiatric Inpatient Units Procedure
The purpose of this Business Continuity Plan (BCP) is to respond to an acute shortage of psychiatric medical staff in WA Country Health Service (WACHS) Acute Psychiatric Units (APUs).
Bed Prioritisation and Bed Closure Procedure - Albany Hospital Acute Psychiatric Unit
Procedure for prioritisation of bed allocation and bed closure under different circumstances.
Best Practice Guidelines Accommodating Older GLBTI People - EUCP in WACHS Residential Aged Care Policy
WACHS endorses these guidelines for use in WACHS Residential Aged Care for staff to adopt, to create an inclusive environment that is accepting and welcoming of all GLBTI people.
Bioclinical Services Clinical Equipment User Manual Library - EUCP Policy
WACHS has endorsed the Bioclinical Services Clinical Equipment User Manual Library for use in clinical practice.
Biomedical Engineering Testing and Tagging of Electromedical Equipment and Cords Addendum
Statement by BME regarding the WACHS electromedical equipment that is tested by BME every 6 months, to the Australian Standard, AS/NZS 3551:2012[1].
Birth Information Sheet and Acknowledgement Form - Bridgetown Hospital
Birth information sheet and acknowledgement form
Bladder Management - Catheter Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management of urinary catheters and bladder washouts throughout the WA Country Health Service.
Bladder Management - Continence Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management of continence throughout the WA Country Health Service.
Blood Fridge Procedure - PathWest On Site
Blood fridge procedure for sites with PathWest. Save the procedure first and then complete relevant sections for your site.
Blood Management Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management of Blood and Blood Products throughout the WA Country Health Service (WACHS).
Boarders Procedure - Albany Health Campus
This site procedure is intended to endorse the hospital's support of boarders where warranted by the patient's condition, differentiate between 'Chargeable' and 'Non Chargeable' Boarders and identify for staff, the processes and procedures that apply for the admission of boarders.
Boarders Procedure - Broome Mental Health Unit
The Consultant Psychiatrist or Duty District Medical Officer may approve a boarder to stay at the Broome Hospital Mental Health Unit when it is clinically assessed as being of benefit to the patient. This includes supporting the patient's cultural needs and / or the patient's care and recovery.
Borrowing Medication for Inpatients from Community Pharmacies Procedure
This document provides guidance for the appropriate acquisition of critical medications from community pharmacies for patients that are inpatients of WACHS - South West facilities outside of Pharmacy hours.
Bowel Management Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care for bowel management throughout the WA Country Health Service (WACHS).
Business Continuity Plan - Albany Health Campus
This procedure applies only to Albany Health Campus.
Business Continuity Plan - Broome Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Business Continuity Plan - Bunbury Hospital
The purpose of the Bunbury Hospital Business Continuity Plan is to outline the principles to be followed, actions to be taken and resources to be used when responding to a critical incident that results in, or has the potential to result in, disruption to critical business functions at the hospital.
Business Continuity Plan - Busselton Health Campus
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Business Continuity Plan - Kimberley Mental Health and Drug Service (KMHDS) Clinics and Offices
BPC formerly included in an overarching document has now been separated specifically for KMHDS.
Business Continuity Plan - Regional Director and Broome Corporate Offices
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.

C

CAHS Community Health Policies, Procedures and Resources (Client and Staff) - EUCP Policy
WACHS has endorsed the CAHS Community Health Policies, Procedures and Resources (Client and Staff).
Cancer Institute NSW Standard Cancer Treatments - eviQ - EUCP Policy
WACHS has endorsed the Cancer Institute NSW - Standard Cancer Treatments - eviQ for use in clinical practice.
Capital Works Program Governance Policy
WACHS Capital Works Program is defined in part by the WA State Health's Infrastructure Projects Governance Framework (2010). In addition, WACHS aims to build on this state wide framework by further describing the accountabilities, roles and responsibilities of key stakeholder involved in the planning and delivery of WACHS' infrastructure projects.
Cardiac Thrombolysis Pack Information Sheet
This information sets out the contents (and related forms) for a cardiac thrombolysis pack which is to be kept in all Emergency Departments / Services to ensure quick and timely reperfusion for patients who require it.
Cardioversion Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management of patients requiring Cardioversion throughout the WA Country Health Service (WACHS).
Care and Discharge of Persons in Custody Policy
From time to time, persons in custody may present for emergency, inpatient or other services at public hospitals. This policy describes the processes, roles and reponsibilities when a person in custody is visiting or receiving care at WACHS site.
Care Location for Acutely Unwell MPS Aged Care Residents Flowchart
This flowchart supports MPS staff in making decisions regarding the appropriate care location for MPS residents who are injured or become acutely unwell.
Care of the Deceased Policy
This policy and related documents are to be implemented in a manner that respects the dignity of the deceased and meets the medico-legal requirements of the organisation without adding to the distress of the family. The deceased, their family and carers are to be treated with respect at all times.
Caregiver's Daily Medication Diary Addendum
This is a caregiver's daily medication diary.
Carer Procedure - Goldfields Mental Health Service
The GMHS acknowledges the capacity of non-professional carers and advocates and the contribution made to support and care for people with mental health problems and mental health disorders, thus establishing and maintain mechanisms for the involvement of carers in provision of service.
Caring for Children in the Workplace Policy
There are exceptional emergency situations where children may need to be in the workplace. This policy outlines the conditions where this may be accommodated.
Case Management Procedure - Goldfields Mental Health Service
This document outlines the case management procedure which is a collaborative process of assessment, planning, treatment, care facilitation, and advocacy to meet an individual's holistic needs to promote recovery.
Central Venous Access Device (CVAD) Management - Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the insertion, management and removal of central venous access devices (CVAD) within WACHS. Note: While this CPS is regarding venous access devices, a minor appendix relating to arterial ports is included in lieu of a separate policy document.
Change in Resident Health - Staff Responsibilities Procedure - Augusta Leeuwin Lodge
This procedure sets out the monitoring and response requirements of staff to residents' health changes.
Chaperone Policy
This policy sets out how the WA Country Health Service (WACHS) is to provide an environment to ensure the safety and comfort of patient by offering a chaperone to attend intimate or other clinical examinations if required.
Checking and Ordering S4R and S8 Medications at Remote Clinics Procedure
This procedure's aim is to reduce the risk of loss or theft of restricted medication while in transit to or from the Remote Area Clinic (RAC).
Chemotherapy Administration Clinical Practice Standard
This CPS has been endorsed for use by WACHS and should be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.
Chest Drain Management - WACHS Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management of chest drains throughout the WA Country Health Service (WACHS).
Chest Pain and Acute Coronary Syndrome Clinical Practice Standard
This CPS has been endorsed for use by WACHS and should be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.
Child and Adolescent Mental Health Service Resources EUCP Policy
The WACHS endorses eleven (11) Child and Adolescent Mental Health Service (CAMHS) Resources as evidence based recommended practice for use by Medical, Nursing, Midwifery and Allied Health staff.
Child and Adolescent Mental Health Services Access Criteria Policy
This policy describes access to Child and Adolescent Mental Health Services (CAMHS) within the WA Country Health Service (WACHS). CAMHS must be accessible to children and their families, and meet the needs of the community in a timely manner.
Chronic Conditions Alert Procedure
This procedure outlines the requirements for clinical staff (medical / nurse / allied health) to ensure correct and consistent application of the Chronic Conditions Alert. It outlines the integration between the clinical, administrative, and Regional Health Information Management (HIM) processes that are to occur within the WA Country Health Service (WACHS).
Cleaning Clinical Equipment Procedure - Great Southern
This procedure sets out the delineation of responsibility for bedside clinical equipment cleaning.
Clinical Audit Policy
The WA Country Health Service seeks to drive service improvements within the system to obtain better health outcomes for consumers. WACHS provides direction and guidance to all staff to ensure the processes for hospital and non hospital clinical audit activities at all levels of the organisation are reliable, valid and timely.
Clinical Audit Proposal and Guidance Form
This form is to be completed for all proposed WACHS clinical audits.
Clinical Escalation of Acute Physiological Deterioration including Medical Emergency Response Policy
This policy addresses the requirements for early recognition of acute physiological deterioration and clinical escalation, including Medical Emergency Response (MER) for adult, maternity, newborn and paediatric patients, inclusive of mental health inpatients and aged care residents within WACHS healthcare facilities. Where a MER is required outside the health campus, ambulance assistance is to be sought by dialling 000 (WACHS staff may be first responders).
Clinical Image Photography and Videography Policy
The purpose of this policy is to provide governance and a policy framework for the WA Country Health Service in relation to the capture, storage and management of clinical images, excluding radiological medical imaging, for clinical care and related purposes, and to ensure that all WACHS staff and contractors are aware of their responsibilities and professional accountabilities for safeguarding the confidentiality and integrity of clinical images.
Clinical Midwife Specialist (Endorsed) Policy
Endorsed Midwives, employed by WACHS (CMS - Endorsed) can prescribe and order diagnostics as per the current legislation to support the delivery of safe and high quality maternal and newborn health care within the WA Country Health Service. This policy provides a standardised governance process and defines the employment pathways for Endorsed Midwives within specific organisational settings. CMS - Endorsed positions will not be supplemental workforce and will be an alternative for existing clinical midwife positions.
Clinical Observations and Assessments CPS (physiological, neurovascular, neurological and fluid balance)
The purpose of this policy is to establish minimum practice standards for physiological (vital signs), neurovascular, neurological and fluid balance observations and assessments throughout the WA Country Health Service.
Clinical Pathology-Investigation Communication Process Flowchart - Wheatbelt
Clinical pathology/investigation communication process for the Wheatbelt.
Clinical Product Evaluation Policy
This policy outlines the process for the evaluation of introduction of clinical products into a clinical area to minimise these risks.
Clinical Products Complaint Policy
The use of clinical products can result in clinical, financial and operational risks. This policy outlines the process for the reporting of products that do not meet expected clinical performance requirements.
Clinical Risk Assessment and Management Procedure - Goldfields Mental Health Service
The aim of this document is to assist the Goldfields Mental Health Service (GMHS) clinicians to implement the CRAM policy and make informed judgements pertaining to risks.
Clinical Service Planning Policy
This policy defines what is a service strategy, a service planning and why plan, provides an outline of the service planning context, describes the cycle of strategy and planning through to review or evaluation, outlines the governance and accountabilities for service strategy development and service planning, describes the key principles underpinning services planning and outlines the service planning process.
Clinical Supervision of Junior Doctors Policy
WACHS employs junior doctors in a variety of locations throughout the state. While locations and service types will vary, WACHS recognises that adequate and appropriate supervision is critical to the training and development of junior doctors. This policy sets out the requirements for supervision of junior doctors.
Clinical Supervision Procedure - Kimberley Mental Health and Drug Service
This procedure sets out how the Kimberley Mental Health and Drug Service (KMHDS) provides staff with the opportunity to access clinical supervision.
Clinical Support Resources Policy
The WACHS endorses for use, evidence based clinical support resources from other WA Health Services and external organisations in addition to clinical policy resources developed by WACHS clinicians. These endorsed resources are searchable via the WACHS HealthPoint Policies webpage, and selected high use resources are also accessible via the WACHS Clinical Support Resources intranet webpage.
Closed Circuit Television (CCTV) Monitoring for Clinical Services in WACHS Mental Health
This policy provides guidance for the responsible use and appropriate management of CCTV for clinical purposes across all WACHS Mental Health sites.
Closed Circuit Television (CCTV) Release Information Sheet - Wheatbelt
This information sheet is designed to provide Wheatbelt Health Service Managers, site staff and Infrastructure and Support Service staff how to process and release Closed Circuit Television (CCTV) footage to police.
Clostridium Difficile Procedure - Case Definition for Collection of Specimen
This document outlines the infection control procedures to aid in the prevention of transmission of C.Difficile at the Kalgoorlie Hospital.
Code Black - Personal Threat Preparedness and Response Procedure - Fitzroy Crossing Hospital
A Code Black is a call for assistance, when any individual (staff, patient or visitor) is at personal threat of harm from an act of aggression. This document outlines the response procedure for a Code Black call.
Code Black - Personal Threat Procedure - Broome Hospital
A Code Black is a call for assistance, when any individual (staff, patient or visitor) is at personal threat of harm from an act of aggression. This document outlines the response procedure for a Code Black call.
Code Black - Personal Threat Procedure - Derby Hospital
A Code Black is a call for assistance, when any individual (staff, patient or visitor) is at personal threat of harm from an act of aggression. This document outlines the response procedure for a Code Black call.
Code Black - Personal Threat Procedure - Halls Creek Hospital
A Code Black is a call for assistance, when any individual (staff, patient or visitor) is at personal threat of harm from an act of aggression. This document outlines the response procedure for a Code Black call.
Code Black - Personal Threat Procedure - Hedland Health Campus
The purpose of this procedure is to outline the emergency responses to an armed or unarmed personal threat, active shooter on site or where it is suspected a child or infant has been abducted.
Code Black - Personal Threat Procedure - Kununurra Hospital
A Code Black is a call for assistance, when any individual (staff, patient or visitor) is at personal threat of harm from an act of aggression. This document outlines the response procedure for a Code Black call.
Code Black - Personal Threat Procedure - Midwest
The WA Country Health Service (WACHS) - Midwest actively encourages a safe workplace by supporting staff, to identify and manage personal threats in the workplace. This procedure sets out how aggression is to be addressed and managed in a clinical capacity, ensuring limited risk to staff.
Code Black - Personal Threat Procedure - Newman Hospital
The purpose of this procedure is to outline the emergency responses to an armed or unarmed personal threat, active shooter on site or where it is suspected a child or infant has been abducted.
Code Black - Personal Threat Procedure - Nickol Bay Hospital
The purpose of this procedure is to outline the emergency responses to an armed or unarmed personal threat, active shooter on site or where it is suspected a child or infant has been abducted.
Code Black - Personal Threat Procedure - Onslow Hospital
The purpose of this procedure is to outline the emergency responses to an armed or unarmed personal threat, active shooter on site or where it is suspected a child or infant has been abducted.
Code Black - Personal Threat Procedure - Paraburdoo Hospital
The purpose of this procedure is to outline the emergency responses to an armed or unarmed personal threat, active shooter on site or where it is suspected a child or infant has been abducted.
Code Black - Personal Threat Procedure - Roebourne Hospital
The purpose of this procedure is to outline the emergency responses to an armed or unarmed personal threat, active shooter on site or where it is suspected a child or infant has been abducted.
Code Black - Personal Threat Procedure - Tom Price Hospital
The purpose of this procedure is to outline the emergency responses to an armed or unarmed personal threat, active shooter on site or where it is suspected a child or infant has been abducted.
Code Black - Personal Threat Procedure - Wyndham Hospital
A Code Black is a call for assistance, when any individual (staff, patient or visitor) is at personal threat of harm from an act of aggression. This document outlines the response procedure for a Code Black call.
Code Black - Personal Threat Response at Remote Area Clinics Procedure
A Code Black is a call for assistance, when any individual (staff, patient or visitor) is at personal threat of harm from an act of aggression. This document outlines the response procedure for a Code Black call at remote area clinics.
Code Black Personal Threat Procedure - Wheatbelt
This procedure sets out the response for a Code Black Personal Threat for the Wheatbelt (including the use of Personal and Fixed Duress Alarms).
Code Blue - Obstetrician and-or Paediatrician Procedure - Bunbury Hospital
Maternity and newborn care is a specialised area and is often already staffed by the most appropriate responders to clinical deterioration. This procedure is to provide further clarification of the specialist staff to be contacted immediately and the actions required in the event of suspected clinical deterioration of the maternal or neonatal patient within the Maternity Unit of Bunbury Hospital.
Code Blue Emergency Bell Testing Procedure - Albany Health Campus
In compliance with the National Safety and Quality Health Service (NSQHS) Standards (version 2) - Standard 8.8, there is a requirement for Raulands Australia to test 100% of the emergency buttons and 20% of all other buttons at the Albany Health Campus (AHC) on an annual basis. This document outlines how this is to be coordinated through Infrastructure and Support Services.
Code Brown - Emergency Response Procedures - South West Health Campus
Code Brown - South West Health Campus An external emergency is defined as a multi-casualty incident that stretches or overwhelms the available health resources, e.g. aircraft crash, structural collapse, explosion.
Code Brown - External Emergency Preparedness and Response Procedure - Kununurra Hospital
This procedure describes the emergency response required when a Code Brown External Emergency has been activated for the Kununurra Hospital and Coolibah Centre.
Code Brown - External Emergency Preparedness and Response Procedure - Wyndham Hospital
This document sets out the response procedure at the Wyndham Hospital if a Code Brown - External Emergency is declared.
Code Brown - External Emergency Procedure - Augusta Hospital
This is the Code Brown - External Emergency response for the Augusta Hospital.
Code Brown - External Emergency Procedure - Boyup Brook Hospital
This is the Code Brown - External Emergency response for the Boyup Brook Hospital.
Code Brown - External Emergency Procedure - Bridgetown Hospital
This is the Code Brown - External Emergency response for the Bridgetown Hospital.
Code Brown - External Emergency Procedure - Broome Regional Health Campus
This document sets out the graduated response required upon the event of a Code Brown External Emergency.
Code Brown - External Emergency Procedure - Collie Hospital
This is the Code Brown - External Emergency response for the Collie Hospital.
Code Brown - External Emergency Procedure - Geraldton Hospital
This procedure outlines the responses required when a Code Brown - External Emergency is declared.
Code Brown - External Emergency Procedure - Harvey Hospital
This procedure outlines the response and roles and responsibilities of staff when a Code Brown External Emergency occurs.
Code Brown - External Emergency Procedure - Nannup Hospital
This is the Code Brown - External Emergency response for the Nannup Hospital.
Code Brown - External Emergency Procedure - Warren Hospital
This procedure outlines the response and roles and responsibilities of staff when a Code Brown External Emergency occurs.
Code Brown - External Emergency Response Procedure - Derby Hospital
This procedure outlines the response required when a Code Brown is declared at the Derby Hospital.
Code Brown - External Emergency Response Procedure - Fitzroy Crossing Hospital
The provision of emergency health services at the Fitzroy Crossing Hospital is based on the principle of a graduated response commencing at a local level, with a gradual escalation to a district response and state level as required with time. This procedure describes the Local Health Emergency Response for the Fitzroy Crossing Hospital.
Code Brown - External Emergency Response Procedure - Halls Creek
This procedure sets out the graduated response required upon the event of a Code Brown External Emergency.
Code Brown - External Emergency Response Procedure - Margaret River Hospital
This is the Code Brown - External Emergency response for the Margaret River Hospital.
Code Brown - Major External Emergency Response at Remote Area Clinics Procedure
This procedure describes the Local Health Emergency Response for One Arm Point, Lombadina, Looma, Warmun, Kalumburu, Bayulu, Mowanjum, Noonkanbah, Wangkatjungka and Yiyili clinics.
Code Orange - Evacuation Procedure - Broome Hospital
This document outlines the procedure to be undertaken if a Code Orange - Evacuation is declared at the Broome Hospital.
Code Orange - Evacuation Procedure - Derby Hospital
This document outlines the procedure to be undertaken if a Code Orange - Evacuation is declared at the Derby Hospital.
Code Orange - Evacuation Procedure - Fitzroy Crossing Hospital
This procedure sets out how an evacuation at the Fitzroy Crossing Hospital to be an organised, controlled movement of people from a danger area to a safer area within an acceptable period of time whenever lives are threatened.
Code Orange - Evacuation Procedure - Midwest
This evacuation procedure aims to assist staff to facilitate an effective, timely and controlled evacuation and minimise subsequent risks and dangers.
Code Orange - Evacuation Procedure - Wheatbelt
The purpose of this procedure is to provide information relevant to an evacuation of an area within or from the facility and to outline the actions for an evacuation of an area within or from the facility.
Code Orange - Evacuation Response at Remote Area Clinics Procedure
This procedure is designed to assist staff who work in remote area clinics to identify and manage events that may threaten harm to staff, clients, carers or visitors.
Code Purple - Bomb Threat Preparedness and Response Procedure - Broome Hospital
This procedure sets out the processes to be followed in preparedness and response to a bomb threat.
Code Purple - Bomb Threat Procedure - Derby Hospital
This document outlines the procedures to be undertaken should there be a bomb, or other suspicious package threat at the Derby Hospital.
Code Purple - Bomb Threat Procedure - East Kimberley
This procedure supports staffs who believe they, patients and/or visitors are at risk of personal threat of actual physical harm from an explosive event or device that may threaten their safety or the integrity of buildings and surrounds.
Code Purple - Bomb Threat Procedure - Fitzroy Crossing Hospital
This document sets out the procedure to be undertaken upon receipt by staff of a threat, or discovery of a suspect object at the Fitzroy Crossing Hospital.
Code Purple - Bomb Threat Procedure - Midwest
This procedure supports staffs who believe they, patients and/or visitors are at risk of personal threat of actual physical harm from an explosive event or device that may threaten their safety or the integrity of buildings and surrounds.
Code Purple - Bomb Threat, Suspicious Mail or Parcel Response at Remote Area Clinics Procedure
This procedure supports staff who may believe they and / or patients are at risk of personal threat or actual harm from an explosive event or device that may threaten their safety, or integrity of buildings and surrounds.
Code Purple - Bomb-Substance Threat Procedure - Wheatbelt
The purpose of this procedure is to provide information on, and outline emergency responses to, a bomb/substance threat (Code Purple).
Code Red - Fire and Smoke Preparedness and Response Procedure - Broome Hospital
A Code Red emergency is declared when FIRE and/or SMOKE is detected. Alerts/Alarms may occur at any time of the day or night and it is essential that the cause is investigated. This document outlines the response procedure for Code Red.
Code Red - Fire and Smoke Preparedness and Response Procedure - Derby Hospital
A Code Red emergency is declared when FIRE and/or SMOKE is detected. Alerts/Alarms may occur at any time of the day or night and it is essential that the cause is investigated. This document outlines the response procedure for Code Red.
Code Red - Fire and Smoke Preparedness and Response Procedure - Fitzroy Crossing Hospital
A Code Red emergency is declared when fire and/or smoke is detected. Alerts/alarms may occur at any time of the day or night and it is essential that the cause is investigated. This document outlines the response procedure for a Code Red call at the Fitzroy Crossing Hospital.
Code Red - Fire and Smoke Preparedness and Response Procedure - Halls Creek Hospital
A Code Red emergency is declared when fire and/or smoke is detected. Alerts/Alarms may occur at any time of the day or night and it is essential that the cause is investigated. This document outlines the response procedure for Code Red.
Code Red - Fire and Smoke Preparedness and Response Procedure - Kununurra Hospital
A Code Red emergency is declared when fire and/or smoke is detected. Alerts/Alarms may occur at any time of the day or night and it is essential that the cause is investigated. This document outlines the response procedure for Code Red.
Code Red - Fire and Smoke Preparedness and Response Procedure - Wyndham Hospital
A Code Red emergency is declared when fire and/or smoke is detected. Alerts/Alarms may occur at any time of the day or night and it is essential that the cause is investigated. This document outlines the response procedure for Code Red.
Code Red - Fire and Smoke Response at Remote Area Clinics Procedure
A Code Red emergency is declared when FIRE and/or SMOKE is detected. Alerts/Alarms may occur at any time of the day or night and it is essential that the cause is investigated. This document outlines the response procedure for Code Red.
Code Red - Fire Safety Procedure - Midwest
This procedure aims to assist staff to prevent the outbreak of fire and minimise subsequent risk / danger in the event that a fire or smoke emergency was to occur.
Code Red - Fire-Smoke Response Procedure - Wheatbelt
The purpose of this section is to outline the fire safety measures in place to prevent and protect staff from fires and emergency responses to a fire and/or smoke (Code Red).
Code Yellow - Business Continuity Plan - Burringurrah Nursing Post
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Carnarvon Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Coolgardie Community Health
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Coral Bay Nursing Post
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Cue Nursing Post
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Derby Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Dongara Health Centre
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Esperance Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Esperance Population Health
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Exmouth Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Fitzroy Crossing Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Geraldton Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Halls Creek Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Kalbarri Health Centre
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction
Code Yellow - Business Continuity Plan - Kalgoorlie Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Kalgoorlie Population Health
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Kambalda Community Health
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Kimberley Aged and Community Services
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Kimberley Population Health Unit
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Kimberley Remote Clinics
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named clinics. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Kununurra Hospital and Coolibah Centre
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Laverton Community Health
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Laverton Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Leinster Community Health
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Leonora Community Health
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Leonora Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Meekatharra Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Menzies Health Centre
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Morawa Perenjori Health Centre
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Mount Magnet Health Centre
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Mullewa Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Norseman Community Health
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Norseman Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - North Midlands Health Service
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Northampton Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Sandstone Nursing Post
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Wyndham Hospital
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Business Continuity Plan - Yalgoo Health Centre
This Business Continuity Plan (BCP) addresses identified risks that potentially impact adversely on the named hospital, facility or service. This BCP details contingency operating plans for critical business functions and their support services in response to any localised incident or disaster as a result of a resource failure or malfunction.
Code Yellow - Cyclone Preparedness and Response Procedure - Kimberley
Code Yellow - Cyclone response for all WACHS-Kimberley hospital sites (includes Action Cards).
Code Yellow - Infrastructure and other internal emergency - Broome Regional Health Campus
This document prescribes actions to be undertaken in case of code yellow related emergencies.
Code Yellow - Internal Disaster Procedure - Wheatbelt
The purpose of this section is to outline the emergency responses to an infrastructure and other internal emergency (includes essential service disruption). These Code Yellow emergency response procedures are to be read in conjunction with the facility's Business Continuity Plan (BCP).
Code Yellow - Internal Emergency Response at Remote Area Clinics Procedure
Code Yellow is a response to an internal emergency. This document outlines the response with specific reference to Tropical Cyclone, Flooding, Storm surge, Tsunami, Earthquake and Bushfire.
Cognitive Impairment Clinical Practice Standard
This policy establishes minimum practice standards for the screening, assessment and management of patients with a cognitive impairment throughout the WA Country Health Service (WACHS).
Colonoscopy Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for elective colonoscopy procedures performed throughout the WA Country Health Service (WACHS).
Coloured Tray Alert Procedure - Midwest
This procedure outlines the use of coloured trays to identify those patients that require feeding and/or setup assistance at meal times.
Committee Risk Reporting Oversight Responsibilities - Wheatbelt
This information sheet outlines the risk reporting monitoring and review responsibilities for the Wheatbelt Executive and Sub-Committees.
Commonwealth Home Support Program for older Australians and National Disability Insurance Scheme Financial Management Policy
The CHSP and NDIS Financial Management Policy has been developed and implemented to provide accurate and timely budgeting, accounting, costing, reporting and acquittal of these programs.
Community Mental Health - Physical Health Screening Procedure
There is significant evidence to demonstrate an association between mental illness and poor physical health. Research, in many countries, has consistently confirmed that psychiatric patients have high rates of physical illness, much of which goes undetected. Such investigations have led to calls for health professionals to be more aware of these findings and for better medical and oral health screening followed by physical and oral health treatment of psychiatric patients.
Community Mental Health Access Procedure - South West Mental Health
This procedure sets out the process for referrals received (i.e. the obtaining of background information by the Access team who then complete a face-to-face assessment to determine the type and urgency of intervention required).
Community Mental Health Case Management Procedure - GS Mental Health Service
This procedure sets out the process for the Case Manager within Community Mental Health to provide coordinated recovery-focused care that involves assessment, treatment and support to both voluntary and involuntary mental health patients, their carers or significant others with clear communication between those involved.
Community Mental Health Clinical Review Procedure - Goldfields Mental Health Service
The purpose of this clinical review procedure is to ensure a consistent and quality approach by all Goldfields Mental Health (GMHS) clinical staff to the assessment, management and care planning for all patients of GMHS.
Community Mental Health Physical Health Procedure - Wheatbelt Mental Heath Service
This procedure provides a structured format for the completion of a physical and oral health examination undertaken by a medical officer.
Community Mental Health Service Documentation Standards for Referrals Procedure - Kimberley Mental Health and Drug Service
Kimberley Mental Health and Drug Service (KMHDS) is a specialist service that provides ambulatory and in patient care to people with mental health conditions and alcohol and or drug problems in the Kimberley region.
Community Mental Health Service Interruption Procedure - GSMHS
This procedure outlines how any interruption to service provision at the Albany, Narrogin and Katanning Community Mental Health clinics are to be managed to ensure clinical services continue to be provided safely to consumers.
Community Mental Health Service Referral and Admission Procedure - Great Southern Mental Health Service
This procedure sets out the prioritisation framework for admission to the Community Mental Health Service based on risk and complexity.
Community Mental Health Triage Procedure - GSMHS
This procedure outlines the provision of inpatient and ambulatory care to mental health patients in the Great Southern Mental Health Catchment Area. The procedure does not apply to Emergency Triage or Disaster Triage.
Community Midwifery - Antenatal Care Guideline
This guideline sets out how antenatal care is provided following a woman and family-centred approach and in a culturally sensitive manner; with the midwife practicing within WACHS endorsed policies, guidelines and procedures, and the registered midwife's scope of practice.
Community Midwifery - Birthing Options and Items for Discussion Information Sheet
This information sheet provides information for pregnant women and is used for recording details of the birthing hospital and services available.
Community Midwifery - Consultation and Referral Pathway - Great Southern
Consultation and referral pathway for pregnant women in the Great Southern region.
Community Midwifery - Consultation and Referral Pathway - Wheatbelt
Consultation and referral pathway for pregnant women in the Wheatbelt region.
Community Midwifery - Fetal Growth and Wellbeing Guideline
This document discusses fetal grown, movements and heart rate, and how to assess fetal wellbeing.
Community Midwifery - Midwifery Care When No Fetal Heart Rate is Detected in the Antenatal Period Guideline
This document outlines how safe, timely and appropriate midwifery care is provided, including support and transfer of the client in the absence of the fetal heart rate during the antenatal period.
Community Midwifery - Postnatal Care Guideline
This document outlines how the community midwifery service provides holistic, evidence-based midwifery care and support for the post-partum woman, her baby and family within the home environment, ensuring appropriate community referral as required.
Community Midwifery - When a Client's Choice of Care is at Variance with the WACHS Standard of Practice Guideline
This document outlines how, as a caregiver, the midwife must provide midwifery care that is consistent with the national professional standards for midwives and is within the scope and boundaries of their practice and those endorsed by WACHS. When a client's decision is at variance from professional advice or guidelines, the midwife must consult and document accordingly.
Complaints Process Flowchart - Wheatbelt
This flowchart sets out the process for managing received complaints in the Wheatbelt region.
Compulsory Reporting of Allegations of Assault on Adult Patients and Protection for Staff Who Report Assault Flowchart
Flow for the compulsory reporting of allegations of assault on adult Patients and protection for staff who report assault.
Compulsory Reporting of Allegations of Assault on Adult Patients and Protection for Staff Who Report Assault Policy
This policy sets out how WACHS staff are to respond appropriately to an alleged victim of assault and how the relevant managers are to report alleged or suspected physical or sexual assault after having reviewed Special Considerations and Additional Reporting Requirements.
Concentrated Potassium-Containing Solution Tracking Sheet
Details for each issue of concentrated potassium-containing solutions (potassium chloride ampoules, potassium dihydrogen phosphate, and 40mmol/100mL bags) are to be recorded in the Concentrated Potassium Containing Products Tracking Sheets (File). Details to be recorded include date and time, ward, patient's name and URMN, quantity issued, dose prescribed, name and signature of person issuing the supply (pharmacy staff or After Hours Hospital Coordinator), and approving consultant / Head of Department as documented on the order.
Consent for sharing of information - Child 0-17 years Procedure - Population Health
This procedure provides WACHS Population Health staff with a process for the disclosure of client information to external parties. It must be read in conjunction with the WA Health system MP 0010/16 Patient Confidentiality Policy.
Consent for sharing of information Form - Child 0-17 years - Population Health
Consent for sharing of information Form - Child 0-17 years - Population Health
Consumer and Carer Engagement Policy
This policy ensures that consumers and carers are included and supported to participate in our health service and care planning, design, delivery and evaluation across our organisation: from supporting consumers to make informed decisions and manage their own health care, to seeking out and learning from the experiences of consumers and carers to improve the safety, quality, and efficiency of our services.
Continuous Subcutaneous Infusions in the Palliative Care Setting Policy
A subcutaneous infusion allows safe and effective continuous administration of medications when other routes are inappropriate or ineffective. Nursing staff caring for a patient with a subcutaneous infusion must have completed the Capabiliti LMS Ambulatory Infusion Pump, NIKI T34 (EQ03 EL1) education program (including face to face training from the regional palliative care coordinators for NIKI pumps), and are to be deemed competent by a member of the regional palliative care team or regional staff development team.
Contrast Extravasation - Outpatient Information Sheet
Outpatient information sheet regarding contrast extravasation.
Cost Planning for Capital Works Project Officers Guideline
This Capital Cost Planning Review guideline has been developed to assist WA Country Health Service (WACHS) capital works staff and stakeholders to understand the process of capital cost planning and to be able to interpret capital cost plans developed for the differing stages of individual projects.
CPDP MR723 State CPDP Inpatient - Care Plan for the Dying Person
CPDP MR723 State CPDP Inpatient - Care Plan for the Dying Person iProc Order Number - 186474A
CPDP MR723.1 State CPDP Community - Care Plan for Dying
CPDP MR723.1 State CPDP Community - Care Plan for Dying iProc Order Number - 186478F
CPDP MR723.2 State CPDP Community - Continuing Goals of Care
CPDP MR723.2 State CPDP Community - Continuing Goals of Care iProc Order Number - 186479G
CPDP MR723.3 State CPDP Community - Action Report
CPDP MR723.3 State CPDP Community - Action Report iProc Order Number - 186480H
CPDP MR723.4 State CPDP Community - Integrated Progress Notes
CPDP MR723.4 State CPDP Community - Integrated Progress Notes iProc Order Number - 186481J
CPDP MR723A State CPDP Inpatient - Continuing Goals of Care
CPDP MR723A State CPDP Inpatient - Continuing Goals of Care. iProc Order Number - 186475B
CPDP MR723B State CPDP Inpatient - Action
CPDP MR723B State CPDP Inpatient - Action Report. iProc Order Number - 186476C
CPDP MR723C State CPDP Inpatient - Integrated Progress Notes
CPDP MR723C State CPDP Inpatient - Integrated Progress Notes. iProc Order Number - 186477E
Creating Safe Workplaces - Setting Up Your Workstation
This guide is based on a risk management approach and proactively sets out ways in which individuals can reduce or avoid injury in the office environment.
Credentialing for Nurse Practitioners and Endorsed Privately Practicing Midwives Policy
The aim of this policy is to establish minimum standards for credentialing, re credentialing and defining scope of clinical practice for nurse practitioners and endorsed privately practising midwives within the WA Country Health Service (WACHS) that complies with state wide policy.
Credentialing Requirements for Non Specialist Surgeons Guideline
The purpose of this document is to assist WA Country Health Service (WACHS) ensure that appropriate credentialing requirements are met with respect to non-specialist doctors providing clinical services in surgery.
Credentialing Requirements for Non-Specialist Anaesthetists Guideline
The purpose of this document is to assist the WA Country Health Service (WACHS) to ensure that appropriate credentialing requirements are met with respect to non specialist doctors providing clinical services in elective anaesthesia.
Credentialing Requirements for Non-Specialist Obstetricians Guideline
The purpose of this document is to assist WA Country Health Service (WACHS) staff to ensure that appropriate credentialing requirements are met with respect to non-specialist medical practitioners providing clinical services as obstetric doctors.
Critical Care of the Obstetric Patient Policy
This policy applies only to Obstetric patients in maternity hospitals with onsite HDU or ICU services (and excludes care relating to the newborn /neonate).
Critical Incident Debriefing for Staff Procedure - Kimberley
This procedure deals with the management and support of staff who may experience stress resulting from a critical incident.

D

Damage to Property Procedure - Broome Mental Health Unit
This document sets out the procedure to be followed if hospital property is damaged as a result of a patient's actions.
Decontamination of Diagnostic Ultrasound Transducers Clinical Practice Standard
As a patient safety initiative to prevent transmission of infection, the purpose of this Clinical Practice Standard (CPS) is to establish minimum practice standards for the decontamination of diagnostic ultrasound transducers throughout the WA Country Health Service (WACHS). This CPS may be used in conjunction with specific site departmental requirements. Information excluded from this CPS comprises: - specific procedural guidelines for sterilisation i.e. operating theatres - procedural guidelines for specific diagnostic ultrasound transducers.
Delivery of Pharmaceutical Products via the Pneumatic Tube System Procedure
A pneumatic tube is used to convey specific items in a fast, safe and efficient manner. Not all items are suitable to send via the pneumatic tube and this procedure outlines what pharmaceuticals are not to be sent.
Development and Publishing of Consumer Information Flowchart - Great Southern
How to develop and publish consumer information
Development, Approval and Publishing of Consumer Information Resources Procedure - Wheatbelt
This procedure deals with information for consumers who access and use the WACHS Wheatbelt health services. It covers information about conditions, treatments, procedures, examination, surgery and services - not personal information. The procedure offers guidance on how to write, present, produce and evaluate the effectiveness of consumer information, not guidance on content.
Diabetes - Inpatient Management Clinical Practice Standard
The purpose of this document is to establish minimum practice standards for inpatient diabetes management throughout the WA Country Health Service (WACHS). This Clinical Practice Standard does not include information on the management of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic state (HHS). For management of these diabetic emergencies refer to specific regional/site instructions. For the management of obstetric, paediatric and neonate patients refer to King Edward Memorial Hospital resources and Princess Margaret Hospital Guidelines endorsed for use in clinical practice
Diagnosis of Malpresentation in Labour Guideline
This guideline aims to ensure early detection of fetal malpresentation in labour to give women and their carers maximum time to consider management options and arrange a care plan consistent with the woman's wishes and optimal fetal safety.
Dietetic Referral Pathways for Elevated BMI in Adults Admitted to Acute Services Guideline
This guideline provides referral pathways for adult inpatients with an elevated BMI to dietetics, with key components being the development of healthy lifestyle education packs and referrals to local outpatient dietetic services. It promotes integration of acute care with community services to ensure improved health outcomes for the patient.
Discharge - Ambulatory (Outpatient) Procedure - Great Southern Mental Health Service
This procedure outlines the minimum standard for discharge from ambulatory Mental Health Services within the Great Southern.
Discharge Against Medical Advice Policy
This policy sets out a person centred care approach that WACHS is committed to providing that will support the delivery of care that is respectful, individualised and empowering when an inpatient chooses to leave the hospital and/or is removed by their parent/carer/responsible person before the completion of treatment against the advice of the treating clinician and a decision is made to discharge.
Discharge from the Emergency Department of Patients with Mental Health Symptoms Procedure - Albany Hospital
This procedure outlines the step by step process for the assessment and referral of patients presenting to the Emergency Department (ED) with mental health complaints or symptoms. Patients may be admitted to hospital, transferred to another hospital or discharged home.
Discharge Lounge Procedure - Geraldton Hospital
This Procedure applies only to the site named here
Discharge of Ngaanyatjarra Lands Patients Procedure - Kalgoorlie Hospital
Discharge of Ngaanyatjarra Lands patients from the Kalgoorlie Hospital.
Discharge Planning from the Goldfields Community Mental Health Service Procedure
This procedure outlines the requirement of Community Mental Health (GCMH) clinicians in relation to discharge of patients from the GCMH Service.
Discharge Planning from the Mental Health Inpatient Unit Procedure - Kalgoorlie Hospital
The Kalgoorlie Mental Health Inpatient Unit's discharge plan contributes to the treatment, support, planning and delivery of follow up by Community Mental Health and other community based services.
Discharged Against Medical Advice Flowchart - Wheatbelt
This flowchart sets out the process to be followed when a patient wishes to discharge against medical advice.
Disposal of Scrap Metal Procedure
The WA Country Health Service (WACHS) is committed to: - disposing of scrap metal via methods that meet all legislative and environmental requirements - ensuring that scrap metal is disposed of via licensed scrap metal merchants - ensuring that any recoup/reimbursement for scrap metal being disposed of is banked to WACHS public funds.
Dissemination of Information Procedure - Kimberley
This procedure outlines the mechanisms in place to notify or distribute policy directives, guidelines, information bulletins and legislation updates to policy and procedure manuals to relevant facilities, managers and staff within the agency, and to any person or provider that must comply with them as a condition of an agreement or contract.
Distance Vision Testing Snellen Procedure
The aim of this document is to guide community health staff to assess and record the visual acuity of older children who are literate in English, utilising distance vision testing known as the Snellen Test.
District Health Advisory Council Guideline
The opportunity and challenge for health service providers and decision-makers in a state the size of WA is to address the complex and diverse health needs of widely spread regional, rural, and remote communities. Via our District Health Advisory Councils, the WACHS seeks a relationship with community members, consumers and carers to achieve a two-way exchange so as to better match service delivery to health need and most importantly, the delivery of consistently safe and up-to-date services.
Disturbed Behaviour Management Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for disturbed behaviour management throughout the WA Country Health Service (WACHS).
Documentation Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for clinical documentation throughout the WA Country Health Service (WACHS).
Documentation of the Paediatric Hydration Status on the MR1 at triage Procedure - Kimberley
The WA Country Health Service - Kimberley (WACHS-K) aims to identify / improve the documentation of the hydration status on all paediatric presentations on the MR1 form.
Dress Code for Staff Procedure - Goldfields
It is the responsibility of all staff to dress in a professional manner. Standard of dress is dictated by the nature of duties, the area in which the work is performed and the degree of contact with both patients and the general public. All staff are to comply with the procedure to ensure a professional and positive image of the organisation is maintained at all times.
Dress Code for Staff Procedure - South West
This procedure sets out the minimum dress code standards to be met by all staff.
Dress Code for Staff, Students and Volunteers Procedure - KMHDS
This procedure sets out the standard of dress and presentation that staff, students and volunteers are required to maintain whilst on duty.
Duress Alarm Procedure
Alarms may be necessary at some health sites, for the personal security of staff members whose duties may expose them to the risk of violent acts, as defined in the Department of Health Prevention of Workplace Aggression and Violence Policy 2004.
Duress Procedure - Kimberley Mental Health and Drug Service
This Procedure applies only to the site named here

E

Ear Tissue Spearing Irrigation and Ear Drop Instillation Procedure
The aim of this document is to guide community health staff on the removal of pus/exudate, foreign objects/debris and softened wax from the external ear canal and instil ear drops as required.
Elective Surgery Waiting List Management Procedure
All patients registered onto the Elective Surgery Waiting List (ESWL) within WA Country Health Service (WACHS) are to be managed in a consistent structured approach in accordance with the requirements of the WA health system MP0050/17 Elective Surgery Access and Waiting List Management Policy.
Elective Surgery Waitlist (WEST) Performance Management Policy
This policy is designed to support regions and sites by outlining measures which may be effective in supporting achievement of WA Elective Services Targets (WEST).
Electroconvulsive Therapy Procedure - Albany Hospital Acute Psychiatric Unit
Great Southern Mental Health Service (GSMHS) strives to provide safe and therapeutic treatment for patients within the least restrictive environment.
Electronic Bed Manager Procedure - Geraldton Hospital
This procedure sets out how effective and efficient communication of patient-specific information is achieved through the use of the Electronic Bed Manager (EBM) which enables various users to access the same information simultaneously, ensuring up to date and timely display of patient specific information.
Electronic Communication with Patients-Clients Procedure - GS MHS
The use of electronic communication with patients/clients is only to occur if there are robust systems to protect the safety, security and confidentiality of all parties and the use is not in conflict with the WA health system Operational Directive OD 0656/16 Employee Use of Social Media Policy.
Electronic Fetal Heart Rate Monitoring Policy
Cardiotocography (CTG) or electronic fetal monitoring (EFM) is the most widely used technique for assessing fetal wellbeing in the developed world. The primary purpose of fetal surveillance by CTG is to prevent adverse fetal outcomes.
Electronic Storage of Purchasing Card Documentation Flowchart - Wheatbelt
Electronic Storage of Purchasing Card Documentation Flowchart
Electronic Transmission of Documents Procedure
A procedure for transmission of electronic documents within and outside of WACHS to minimise loss of information through inadequate transmission methods.
Emergency (Disaster) Management Arrangements Policy
The WA Country Health Service is committed to supporting the Department of Health in its designated functions under the Emergency Management Act, 2005 as a Hazard Management and Support Agency. These responsibilities include the provision of health disaster management services during any emergency, which involves a multi agency response, multiple casualties or a public health threat. WACHS has a legislated requirement to instigate procedures to guide a structured response to emergencies at the local and regional levels.
Emergency Care Access Policy
The 2009 WA Health Four Hour Rule Program evolved into the National Emergency Access Target (NEAT). Following the expiry of the Commonwealth National Partnership Agreement on Improving Public Hospital Services in 2015, WA Health established the Western Australia Emergency Access Target (WEAT) in January 2016 to continue to drive local improvement in patient access to emergency services. This policy is designed to support regions by outlining a number of measures identified as effective in supporting 90 per cent.
Emergency Department - Did Not Wait Flowchart - Wheatbelt
This flowchart outlines the process to be followed for patients that present to the ED, but who do not wait.
Emergency Department Acute and Outpatient Activity Classification and Recording Guideline
The Emergency Department (ED) care setting is used to deliver a range of services that include both emergency acute care and outpatient clinics. Classification and recording of these different types of services is required to ensure patient activity is captured appropriately, supports operational requirements and complies with state and national data collection standards.
Emergency Department Discharge Medication Supply Procedure - South West
The following information relates to the appropriate supply of medication to patients upon discharge from WA Country Health Service (WACHS) Emergency Departments (ED) in the South West region. The process to follow is dependent on the resources available to the individual ED.
Emergency Department Discharge Medication Supply Procedure - Wheatbelt
The provision of discharge medications to ED patients is at the prescriber's discretion. It may be necessary for the medical practitioner to dispense, where a pharmacist or retail pharmacy is unavailable, sufficient medication on discharge until a discharge prescription can be filled. The medical practitioner is to make a written record of the medication dispensed at the time of supply and the medication is to be labelled in accordance with the Medicines and Poisons Act 2014 (WA) and Medicines and Poisons Regulations 2016.
Emergency Department Sexual Assault Presentation Procedure - South West
This procedure is for doctors, nurses and health care workers caring for people who have been recently sexually assaulted.
Emergency Escalation and Support for Remote Area Clinics Procedure
The purpose of this document is to provide all WA Country Health Service (WACHS) Kimberley remote area clinic staff with the procedure to use when the WACHS Kimberley Executive On Call is to be contacted (1800 669 229). Contact is to be made with any event, request or incident which impacts significantly on the functioning of the clinic and staff working within the remote area clinic. These instructions apply only to out-of-business-hours events occurring after 16:30 hours and before 08:00 hours and at any time over a weekend or public holiday. During normal business hours, escalation is to the Remote Clinic Coordinator (contact 9194 1638 or 0429 695 548).
Emergency Management - Quick Reference - Immediate Action Procedure (Community Facilities)
Telephone quick access sheets which include Colour Code Chart, Bomb Threat card, Offender ID sheet, CETHANE
Emergency Management - Quick Reference - Immediate Actions Procedure (Hospitals)
Telephone quick access sheets which include Colour Code Chart, Bomb Threat card, Offender ID sheet, CETHANE
Emergency Management - Reporting of Emergencies Procedure
This procedure covers the emergency codes detailed in AS 4083:2010 and AS 3745:2010 with the exception of Code Blue - Medical Emergencies. For advice on Code Blue - Medical Emergencies, please refer to the WACHS Clinical Escalation Including Code Blue Medical Emergency Response (MER) Policy
Emergency Management - Situation Report Procedure
Communicating with key stakeholders is critical to successfully managing an incident or emergency. As an incident evolves, stakeholders who are or maybe impacted by the incident are to be regularly apprised of the situation and actions that need to be undertaken.
Emergency Management Operational Working Group - Terms of Reference
The purpose of the WACHS Emergency Management Operational Working Group is to operationalise the framework for regional health emergency and disaster response, communication and education, in line with the WACHS Emergency Management Executive Subcommittee Business Plan. It ensures consistent and coordinated emergency and disaster preparedness across WACHS including response plans, training / education, reporting, and evaluation, and undertakes work and initiatives, as directed by the WACHS Emergency Management Executive Subcommittee.
Emergency Medical Support for the Unwell Patient for Remote Area Nursing Posts Procedure
This procedure outlines the process for clinical escalation for a patient from the Bremer Bay Health Centre and Jerramungup Nursing Post, who requires medical advice or evacuation where care needed is greater than the available resources, or is outside the scope of practice of the registered nurse (RN) or nurse practitioner (NP).
Emergency Response - Code Black Personal Threat - Albany Health Campus
This Procedure sets out the emergency response to a Code Black (Personal Threat) at the Albany Health Campus.
Emergency Response Procedure - Leonora Hospital
Emergency response procedures for Leonora Hospital
Emergency Response Procedure - Norseman Hospital
Emergency response procedures for Norseman Hospital.
Emergency Response Procedure Esperance Health Campus
Prescribed emergency procedures for Esperance Hospital
Emergency Response Procedures - Augusta MPS
This document contains all the Emergency Response Procedures for the Augusta Hospital and Leeuwin Lodge (with the exceptions of Code Blue, Code Brown - External Emergency and Code Yellow - Business Continuity Plan (BCP) and Missing Person). It supersedes the previous, individual Codes Red, Orange, Black, Purple, Black and Yellows (excepting the BCP).
Emergency Response Procedures - Boyup Brook Hospital
This manual contains all the Emergency Response Procedures for the Boyup Brook Health Service (with the exceptions of Code Blue, Code Brown - External Emergency and Code Yellow - Business Continuity Plan (BCP)). It supersedes the previous, individual Codes Red, Orange, Black, Purple and Yellows (excepting the BCP).
Emergency Response Procedures - Bridgetown Hospital
This manual contains all the Emergency Response Procedures for the Bridgetown Hospital except Codes Brown - External Emergency, Code Blue - Medical Emergency Response, and the Code Yellow - Business Continuity Plan (BCP).
Emergency Response Procedures - Busselton Health Campus
This manual contains all the Emergency Response Procedures for the Busselton Health Campus except the Code Yellow - Business Continuity Plan (BCP).
Emergency Response Procedures - Collie Health Service
This manual contains all the Emergency Response Procedures for the Collie Health Service (with the exceptions of Code Blue, Code Brown - External Emergency and Code Yellow - Business Continuity Plan (BCP)). It supersedes the previous, individual Codes Red, Orange, Black, Purple and Yellows (excepting the BCP).
Emergency Response Procedures - Denmark Health Service
Emergency Response Procedures for Denmark Health Service
Emergency Response Procedures - Donnybrook Hospital
This manual contains all the Emergency Response Procedures for the Donnybrook Hospital (with the exceptions of Code Blue, Code Brown - External Emergency and Code Yellow - Business Continuity Plan (BCP)). It supersedes the previous, individual Codes Red, Orange, Black, Purple and Yellows (excepting the BCP).
Emergency Response Procedures - Dugan Street Kalgoorlie
Emergency response procedures for 7-9 Dugan St site in Kalgoorlie.
Emergency Response Procedures - Gnowangerup Health Service
Emergency Response Procedures - Gnowangerup Health Service
Emergency Response Procedures - Harvey Hospital
This manual contains all the Emergency Response Procedures for the Harvey Hospital (with the exceptions of Code Brown - External Emergency and Code Yellow - Business Continuity Plan (BCP)).
Emergency Response Procedures - Jerramungup and Bremer Bay
Emergency Response Procedures - Jerramungup and Bremer Bay
Emergency Response Procedures - Kalgoorlie Health Campus
The aim of this procedure is to make available to all staff information covering the safe management of emergency situations at Kalgoorlie Health Campus sites.This includes environmental and physical disasters such as fire, flood, earthquake, cyclone, bomb threat, personal threat & evacuation.
Emergency Response Procedures - Katanning Health Service
Emergency Response Procedures - Katanning Health Service
Emergency Response Procedures - Kojonup Health Service
Emergency Response Procedures for Kojonup Health Service
Emergency Response Procedures - Laverton Hospital
Emergency response procedures for Laverton Hospital
Emergency Response Procedures - Margaret River Hospital
This manual contains all the Emergency Response Procedures for the Margaret River Hospital except Codes Brown - External Emergency, Code Blue - Medical Emergency Response, and the Code Yellow - Business Continuity Plan (BCP).
Emergency Response Procedures - Nannup Health Service
This document contains the emergency preparedness and response procedures for the Nannup Health Service
Emergency Response Procedures - Pemberton Hospital
This document contains the emergency preparedness and response procedures for the Pemberton Hospital.
Emergency Response Procedures - South West Health Campus
This document contains all the Emergency Response Procedures for the Bunbury Health Campus (with the exceptions of Code Blue (Medical Emergency Response) Code Brown (External Emergency) and Code Yellow - Business Continuity Plan (BCP)). It supersede the previous, individual Codes Red, Orange, Black, Purple and Yellows (excepting the BCP).
Emergency Response Procedures - South West Regional Aged Care
This manual contains all the Emergency Response Procedures for the South West Regional Aged Care (with the exceptions of Code Blue, Code Brown - External Emergency and Code Yellow - Business Continuity Plan (BCP)). It supersedes the previous, individual Codes Red, Orange, Black, Purple and Yellows (excepting the BCP).
Emergency Response Procedures - The Palms Kalgoorlie
Emergency response procedures for Goldfields Regional Office at The Palms, 68 Picadilly St, Kalgoorlie.
Emergency Response Procedures - Warren Hospital
This document contains all the Emergency Response Procedures for the Warren Health Service (with the exceptions of Code Blue, Code Brown - External Emergency, Code Yellow - Business Continuity Plan (BCP) and Missing Person).
Emergency Response Procedures Bunbury-Leschenault Community Health Centre
This manual contains all the Emergency Response Procedures for the Harvey Hospital (with the exceptions of Code Blue, Code Brown - External Emergency and Code Yellow - Business Continuity Plan (BCP)).
Emergency Response Procedures -Ravensthorpe
Emergency Response Procedures -Ravensthorpe
Employee Access to Nicotine Replacement Therapy Procedure
This procedure describes the process for supporting WACHS staff to quit smoking or manage their nicotine dependence while in a smoke free work setting.
Employee Application for Nicotine Replacement Therapy Form
This form is completed by employees who wish to take up the offer of 8 weeks free Nicotine Replacement Therapy.
Employee Assistance Program Policy
As part of the commitment to ensuring a healthy workforce, the WA Country Health Service (WACHS) provides an Employee Assistance Program (EAP) for all employees and their immediate families.
Employee Breastfeeding Policy
This policy clarifies breastfeeding break requirements, details employee and manager responsibilities, and outlines how finalised breastfeeding agreements are to be forwarded to local Human Resources teams for evaluation and reporting purposes.
Employee Clinical Supervision Procedure - Goldfields Mental Health Service
This document is aimed to address the clinical supervision needs of nursing staff and allied health professions within the Goldfields Mental Health Service (GMHS). Editable versions of appendices available to the right of screen under 'Related Documents / Forms'.
Employee Development Policy
The WA Country Health Service (WACHS) is committed to promoting and supporting effective workplace performance through performance and skills development. Effective workforce performance supports achievement of WACHS strategic priorities and regional action plans.
Employee Record of Attendance Policy
This policy outlines the requirements (under Treasurer's Instruction 502) regarding employee record of attendance processes which applies to all employees at all levels, including Senior Officers, who work within WACHS.
Employee Residential Accommodation Policy
This policy aims to outline the circumstances in which WACHS will provide access to subsidised accommodation to our staff in the interests of WACHS being able to secure staff in areas of significant workforce shortage.
Endoscope Reprocessing Procedure - Great Southern and Midwest
Where endoscopes are used and reprocessed, the health service must comply with current relevant legislation, national and international standards, guidelines and manufacturer's reprocessing instructions.
Engaging Consumers in Workforce Training Guideline
This guideline sets out how WACHS involves consumers in the design and delivery of clinical and non-clinical workforce training - one of the ways we can use consumer perspectives and experiences to improve our services and ensure an ongoing focus on patient-centred care.
Enhanced Child Health Schedule Guideline
In order to optimise the health, development and wellbeing of vulnerable children, the Enhanced Child Health Schedule (ECHS) has been developed to assist families who require Universal Plus and/or Partnership levels of service. Vulnerable populations may include; Aboriginal families, refugee families, children of teenage parents, children of parents with mental illness, children of parents affected by drugs and alcohol, or children with disabilities. Consideration should also be given to offering the ECHS to children with an active WebPAS Child at Risk alert.
Enhanced Observation Procedure - Goldfields Mental Health Service
This procedure ensures that decisions about the level of patient observation are based on the assessment of the patient's level of risk, and that their safety and wellbeing, and the safety of others, is to be safeguarded at all times.
Enrolled Nurse to Advanced Skills Enrolled Nurse Classification Flowchart
This flowchart outlines the process to be followed by the enrolled nurse, the Regional Director of Nursing and Midwifery, and the Executive Director of Nursing and Midwifery Services.
Enteral Tubes and Feeding - Adults Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management of enteral tubes and feeding throughout the WA Country Health Service (WACHS).
Environmental Cleaning Policy
This policy supports the WA Country Health Service (WACHS) Infection Prevention and Control Policy.
Epidural-Spinal Analgesia Management Policy
The purpose of this policy is to ensure safe, effective analgesia or anaesthesia, care and ongoing maintenance for all patients receiving epidurals/spinals within the WA Country Health Service. Please direct any medical queries to the Clinical Lead Anaesthetics (Dr Pat Coleman).
Ethical Decision Making for Clinical or Patient Care Issues Guideline
The purpose of this document is to provide guidance to WA Country Health Service (WACHS) staff who are faced with a difficult ethical decisions. Ethics is about ways in which we do, and should, treat each other. This extends from the 'bedside to the boardroom' and everywhere in between, and includes individuals as well as groups.
External Audit Monitoring and Coordination Procedure
This procedure sets out the arrangements for the monitoring and coordination of external audits. Audits are either internal or external audits. For information on the management of 'internal' audits please refer to the WA Country Health Service (WACHS) Internal Audit Management and Coordination Procedure.
External Cardiac Pacing Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management of External Cardiac Pacing throughout the WA Country Health Service (WACHS).
Eyes Management Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for eye care and management throughout the WA Country Health Service (WACHS).

F

Falls Prevention and Management Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the prevention and management of falls throughout the WA Country Health Service (WACHS).
Family and Domestic Violence Leave Procedure
This procedure outlines how Family and Domestic Violence Leave entitlement is to be applied. It does not capture all scenarios that may arise but is a minimum standard to be complied with.
FDV950 State Screening for Family and Domestic Violence
FDV950 State Screening for Family and Domestic Violence. iProc Order Number - 186679B
FDV951 State Assessment for Family and Domestic Violence
FDV951 State Assessment for Family and Domestic Violence. iProc Order Number - 186680C
FDV952 State Referral for Family and Domestic Violence
Print on site
FemoStop Compression Procedure - Post Anaesthetic Care Unit - Geraldton Hospital
The aim of the procedure is to guide nursing practice in the assistance of the application of a femoral compression device. This is to ensure safe and therapeutically correct techniques are utilised by staff to minimise the risk to the patient when controlling bleeding post femoral artery therapeutical or diagnostic catheterisation. Geraldton Hospital only undertakes lower limb, (including iliac artery) and upper limb angiograms and angioplasty.
Fire Evacuation Emergency Response Procedure - Wheatbelt Mental Health Service
Northam and Gingin satellite office only. Merredin and Narrogin refer to local site procedures - Code Red. The purpose of this procedure is to supplement the Code Red - Fire/Smoke Response Procedure - Wheatbelt for specific stand-alone sites Wheatbelt Mental Health Northam and Gingin offices. Merredin and Narrogin staff are co-located in Ambulatory Care buildings and should follow local hospital procedures.
Flexible Accommodation Procedure - Wheatbelt Mental Health Service
This procedure sets out the details around access to the WMHS flexible accommodation program for youth and adults over 16 years of age.
Flexible Working Arrangements - Application Form
This form relates to Flexible Working Arrangements (FWA) Policy.
Flexible Working Arrangements - COVID-19 Agreement
This template relates to Flexible Working Arrangements (FWA) Policy.
Flexible Working Arrangements - Management Response
This template relates to Flexible Working Arrangements (FWA) Policy.
Flexible Working Arrangements Policy
The Flexible Working Arrangements (FWA) Policy facilitates the daily management of flexible working arrangements. This policy outlines what may be used to develop a FWA, how to request a FWA, how managers should respond to a request and the necessary forms required to document the request.
Fluoride Varnish Procedure
This document sets out the safe and consistent application of fluoride varnish to prevent tooth decay for children.
Food Allergy Guideline
This document is designed to assist staff to identify patients entering the health service with known food allergies and/or intolerances, and provide guidance on the management of these patients during their hospital stay.
Foot and Nail Care Procedure - Midwest
Staff undertaking roles covered by this procedure are responsible to ensure they are informed and comply with this procedure.
Fraud and Corruption Control Plan
This Fraud and Corruption Control Plan (the Plan) has been developed to detail WA Country Health Service (WACHS) approach to fraud and corruption prevention, detection, response and reporting. The purpose of the Plan is to reduce the potential for fraud and corruption to occur and to build a culture within WACHS seeking to prevent fraudulent and corrupt behaviour. This Plan describes: - The roles and responsibilities of individuals and business areas within WACHS regarding the prevention and management of fraud and corruption - What fraud and corruption is and the process of detecting and reporting fraud and corruption - WACHS fraud and corruption risk identification process and controls - How reports of alleged fraud and corruption are investigated or referred to external agencies - How any suspected allegations of fraud or corruption will be managed, reported and dealt with.
Freedom of Information and Release of Information Procedure - WACHS Command Centre
This procedure provides administrative assistance to WACHS Command Centre (CC) staff in responding to external requests for information under the Freedom of Information (FOI) Act 1992 (WA). It also outlines a process for responding to other requests for access to information, including personal (or patient) information relating to a CC event. The majority of requests for release of information received within the CC are referred through regional health facilities. These include requests for verbal and/or written medical reports.
Freedom of Information Procedure - Kimberley
This document outlines the process for the handling of FOI applications in the Kimberley region.
Freedom-Release of Information Process Responsibilities Procedure - Great Southern
This procedure identifies the key staff responsible, and the key process required for the release of health information requests. All flowcharts have been designed to ensure the WACHS Great Southern meets its obligations under the Freedom of Information Act 1992.
Fundraising Procedure - Kalgoorlie Health Campus
This document sets out the procedures and responsibilities around fundraising activities at the Kaloorlie Health Campus.

G

GENCA Guideline for Infection Control in Endoscopy EUCP Policy
This GENCA guideline is endorsed for use in WACHS as evidence-based recommended practice for use by medical, nursing, an non-clinical sterilising services staff.
General Ward Mental Health Consultation and Liaison Service Procedure - Albany Hospital
This procedure sets out the process around access to the Great Southern Mental Health Service's Mental Health Consultation and Liaison service for patients admitted to the general medical and surgical units of the Albany Hospital.
Gifts, Benefits and Hospitality Declaration Procedure
This procedure outlines the steps to be followed by all WACHS staff for declaring gifts that have been offered to them in the course of their employment.
Global Email Messages Policy
This policy applies to the development, approval and publication of global emails issued under the authority of the Chief Executive Officer and Chief Operating Officers (COOs) for distribution across the whole of WACHS.
Guidance for Nursing Staff Managing the Care and Comfort of Patients in the Emergency Department Awaiting Treatment
The purpose of this guideline is to maintain minimum nursing practice standards for the care and comfort of patients awaiting treatment in all WA Country Health Service (WACHS) emergency facilities and act as a prompt to determine if additional comfort needs are required.

H

Hand Hygiene Policy
The objective of this policy is to promote prevention and control of HAIs and improve patient safety, by endorsing the recommendations outlined in the WHO guidelines on HH in health care and the National Hand Hygiene Initiative (NHHI)
Handling and completion of entries in Schedule 4 Restricted and Schedule 8 Registers and Requisitions Books Information She
This document provides guidance on the completion and handling of S4R and S8 registers and requisition books.
Handling and Storage of Patient's Own Medications - Including Schedule 4 Restricted And Schedule 8 Medications Procedure
Patients are encouraged to bring in their own medications on arrival to the hospital. Upon admission, patient's own medications are to be obtained to facilitate accurate medication reconciliation and prescribing. It may also be necessary to utilise patient's own medications in the short term if it is not available in the hospital, to enable continuation of essential medications.
Handling and Supply of Concentrated Potassium-Containing Solutions Procedure
This procedure limits the availability of concentrated-containing potassium solutions, and provides guidance to accessing these, especially outside of pharmacy opening hours.
Handling of Expired Medicines, Excess Stock and Pharmaceutical Waste Disposal Procedure WACHS -South West
This procedure is to provide guidance for nursing and medical staff in the appropriate handling of expired drugs, excess stock and pharmaceutical waste disposal in the WACHS-SW region.
Hazard-Incident Management Procedure
This procedure outlines the requirements for the investigation and reporting of workplace safety hazards and incidents in WA Country Health Servicesites or in the course of conducting WACHS business. It also outlines the procedural requirements for the statutory reporting of notifiable work-related injuries and diseases, a requirement of employers under the Occupational Safety and Health Act 1984 (the Act).
HCARe CMI Client Identification Data Entry Procedure - Kimberley
This procedure provides the business rules and data entry standards for HCARe CMS which is the central Patient Administration System currently used in the WA Country Health Service region of Kimberley. As the prime source of data used for Patient Management, and National, State and Local reporting requirements, these standards aim to provide consistent and high quality data collection across WACHS sites. This document supersedes the 'HCARe CMS CMI Client Identification Data Entry Standards Policy' April 2013.
Health Promotion Policy
The WA Country Health Service (WACHS) actively encourages all employees of the organisation to incorporate national, state and regional health priorities into their work in order to improve the health and well being of employees, clients and the wider community.
Health Record Auditing Procedure
This procedure outlines the standard tools to be used in auditing of health records, their accessibility, storage areas and their disposal, methodology of auditing of health records, nominated staff required to undertake health record audits and reporting and evaluation compliance post audit completion.
Health Record Form Design Guideline
The Australian Standard for Healthcare Records (AS2828) contains comprehensive form design detail. This guideline describes the fundamental principles associated with these.
Health Record Form Management Policy
This policy outlines how the WA Country Health Service upholds stringent record keeping and documentation standards ensuring the health record form complies with the Australian Standards (AS2828) for Paper Based and/or Digitized (scanned) health records and the mandatory Forms Print Management Contract (HCNS 219707) for high usage forms (3000+ copies per annum).
Health Record Management Policy
This purpose of this policy is to provide guidance on the governance, management, creation, content, filing, accessibility, storage, and disposal of health records within the WA Country Health Service.
Healthdirect - Community Nursing Health Institute - EUCP Policy
WACHS has endorsed the Healthdirect Community Nursing Resources for use in clinical practice.
High Flow Humidified Oxygen via AIRVO Bunbury Hospital Information Sheet
Provide updated guidelines relating to the management of patients undergoing High Flow Humidified Oxygen (HFHO) therapy via AIRVO in the ward environment.
High Risk Medications Procedure
This procedure highlights the specific medications and processes for WA Country Health Service (WACHS) sites relating to the storage, handling, prescription, administration and dispensing of high risk medications to improve patient safety.
Home and Community Visits in the Remote Area Community Setting Procedure
This document outlines the procedure for Remote Area Nurses in the provision of an on-call after hours' emergency service to the remote community.
Hospital and Health Service Infectious Disease of Significance or Outbreak Management Procedure - Great Southern
This document sets out the procedure for timely identification and notification of any suspected case of a notifiable infectious disease with prompt implementation of appropriate disease management, transmission precautions and contact follow up protocols will reduce the risk of further transmission and outbreak.
Hospital Chaplaincy Services Procedure - Albany Health Campus
In accordance with the WA Health Volunteers Policy all clergy and church affiliated volunteers who wish to visit patients in an official church capacity at the Albany Health Campus, is required to be formally approved by the health service to do so.
Hospital Chaplaincy Services Procedure - East Kimberley
The WACHS-Kimberley is committed to supporting the social, emotional and spiritual well-being of health service patients and supports appropriate visiting chaplaincy services being available to patients. In accordance with the WA Health Volunteer Policy, all clergy and church affiliated volunteers who request to visit patients in an official church capacity at East Kimberley hospitals are required to be formally approved by the health services to do so.
Hospital Supply of Nutrition Support Products and Feeding Equipment - Midwest
This document aims to provide the clinician with information of the strict criteria for provision of NSPs and consumables to community-based clients located in the Midwest region where it is deemed essential for optimising nutrition care, and who have significant difficulties financially meeting the costs of these products.
Hot and Cold Gel Pack Application Procedure - Albany Hospital
The application of local heat/cold to muscles can assist in relaxation, comfort and provide some relief for aches and pains. The purpose of this procedure is to draw to attention to the potential for injury to patients, when hot or cold packs are applied to the skin.
How to 'Pin' the Clinical Support Resources Webpage to the Start Menu - Information Sheet
Instructions on how to 'pin' the Clinical Support Resources webpage quick link to the start menu of WACHS computers.
Human Research Ethics Committee - Terms of Reference
The HREC ensures all human research undertaken within or involving WACHS by internal or external applicants meets the ethical and scientific standards established by the NHMRC National Statement on Ethical Conduct in Human Research (2007)(as updated) (National Statement) guidelines. The HREC lies within the Ethics Review Function of the WACHS Research Governance Framework.
Human Research Ethics Committee Appointment Policy
This policy outlines the recruitment process, appointment process and terms of appointment for members of the HREC, including new members and existing members.
Human Research Ethics Committee Procedure
These procedures outline the processes to which the WACHS Human Research Ethic Committee is to operate.
Humidified High Flow Nasal Cannula Therapy ADULTS Procedure - Kununurra Hospital
Procedure for the administration of Humidified High Flow Nasal Cannula (HHFNC) therapy for ADULTS at the Kununurra Hospital.
Humidified High Flow Nasal Cannula Therapy ADULTS Procedure - Nickol Bay Hospital
Humidified High Flow Nasal Cannula (HHFNC) therapy is a simple to use system that delivers warm, moist gas from room air to variable oxygen concentrations at high flow rates that generate positive airway pressure.
Humidified High Flow Nasal Cannula Therapy PAEDIATRICS Procedure - Karratha Health Campus
Humidified High Flow Nasal Cannula (HHFNC) therapy is a simple to use system that delivers warm, moist gas from room air to variable oxygen concentrations at high flow rates that generate positive airway pressure.
Humidified High Flow Nasal Cannula Therapy PAEDIATRICS Procedure - Kununurra Hospital
Procedure for the administration of Humidified High Flow Nasal Cannula (HHFNC) therapy for PAEDIATRICS at the Kununurra Hospital.
Humidified High Flow Nasal Cannula Therapy Procedure - Acute Paediatric - Albany Health Campus
This procedure outlines the indications, management and process for the use of Humidified High Flow Nasal Cannula Therapy (HHFNC) in paediatric patients within Emergency Department (ED), High Dependency Unit (HDU) and the Paediatric Ward at the Albany Health Campus.
Hyperacute Stroke Flowchart - Wheatbelt
Hyperacute Stroke Flowchart for the Wheatbelt region

I

Identification of Staff and Official Visitors Procedure - Busselton Health Campus
To maintain a safe and secure environment, the Busselton Health Campus (BHC) requires all its employees (permanent and casual) to wear photo identification at all times while on duty. All Official Visitors to the BHC must also wear an identification badge while on the premises of the BHC.
Identifying and Responding to Family and Domestic Violence Policy
The aim of this policy is to: - ensure consistent minimum standards for WACHS clinicians with regard to identifying and responding to disclosures of family and domestic violence; - support early detection of clients at risk of family and domestic violence; - improve staff awareness of the possible indicators of family and domestic violence; - improve the safety of women and children; and - ensure compliance with S28b, Children and Community Services Act 2004.
Identifying, Preventing and Responding to Abuse of Older People Policy
Abuse of an older person is a violation of basic human rights and in addition abuse is likely to be inconsistent with other legal obligations. Every person has a right to live safely and without fear of abuse, neglect, violence or exploitation. Older adults can be at increased risk of abuse because of vulnerabilities in their physical or mental health, or their financial or social circumstances. The aim of this policy is to: - inform staff and volunteers how to identify an older person who may be at risk of, or experiencing abuse - educate all staff and volunteers on how to prevent or reduce the incidence of abuse of the older person - provide clear role expectations of staff and volunteers in how to respond to alleged abuse - ensure consistent minimum standards for WACHS senior clinicians and line managers with regard to responding to disclosures of alleged abuse of the older person - achieve an integrated and standardised approach to the management of abuse of the older person, while respecting the rights of older people to make their own decisions.
Imaging Clinical Practice Standard
The purpose of this policy is to establish minimum practice accreditation standards and requirements for the care and management of Imaging throughout the WA Country Health Service (WACHS).
Imminent Unplanned Birth at a Non-Birthing Site Policy
This policy applies to the WACHS hospitals which do not provide designated labour and birth services, and ensures that pregnant women who live in communities without hospitals which provide planned birthing services are referred to an appropriate level maternity service to book for labour and birth care. (For an editable Appendix 2 - see 'Related Documents/Forms' on the right hand side of this page.)
Impaired Skin Integrity Clinical Practice Standard
This CPS has been endorsed for use by WACHS and should be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.
Implementing Coroner's Recommendations Procedure
This procedure outlines the process by which a Coronial Report into a death is communicated to the WA Country Health Service from the State Coroner's office; key positions responsible for responding to and implementing the Coroner's recommendations; WACHS reporting obligations with respect to the implementation of the Coroner's recommendations.
Individual Patient Care Planning Meetings - Albany Hospital Acute Psychiatric Unit
This procedure supports a key principle of The National Standards for Mental Health Service in that consumers are given the right to have nominated carer(s) involved in all aspects of their care.
Induction and Orientation Policy
The WA Country Health Serviceis committed to the orientation of all new employees. The orientation process provides employees with key information that outlines the duties and responsibilities relevant to all new staff and their employment and workplace as well as overall information of WACHS that describes the structure of the organisation, the strategic direction, values and policies and procedures.
Induction of Labour Policy
This policy aims to support evidence based decision making involving sound clinical judgement that aligns with the wishes of the woman. It is hoped that this would reduce unwarranted variation in clinical practice whilst continuing to provide high standards of care
Infection Control Link Nurse Role in Governance Arrangement for NSQHS Standard Three Guideline - Great Southern
The National Safety and Quality Health Service Standard Three: Preventing and Controlling Healthcare Associated Infections outlines the governance standards for health service organisations to safely meet the needs of consumers. The role of Infection control link nurses within the Great Southern forms part of the Great Southern governance process.
Infection Control Portfolio Holders Procedure - Kimberley
This procedure sets out the roles and responsibilities of Infection Control portfolio holders (registered nurse/midwife or enrolled nurse delegated the portfolio) who assist their line manager in infection prevention and management at their local unit or site.
Infection Prevention and Control Policy
This policy applies to all employees, students, contractors, volunteers, visitors and carers within WACHS. Standard and additional infection control precautions are to be applied in order to minimise the risks of infection.
Information and Communications Technology - Change Management Procedure
Information Technology Service Management (ITSM) referred to as Change Management, is the method for the WACHS ICT of tracking, approving, scheduling, and communicating, through a managed process for changes to the WACHS managed technical environment.
Information and Communications Technology - Data Backups Procedure
This procedure has been developed to ensure that all aspects of backup processes and procedures are identified and adhered to by WACHS Information and Communications Technology (ICT) staff.
Information and Communications Technology - Disaster Recovery Plans Procedure
This procedure has been developed to ensure that all aspects of Disaster Recovery Plans are identified, regularly updated and reviewed by WACHS Information and Communications Technology (ICT) departments in all regions.
Information and Communications Technology - Uninterruptible Power Supply Procedure
This procedure has been developed to ensure that all aspects of the Uninterruptible Power Supply (UPS) unit processes and procedures are identified and followed by WACHS Information and Communication Technology (ICT) departments in all regions.
Information and Communications Technology - User Access Procedure
This procedure has been developed to ensure that all aspects of user access to the Health network and terminations of users from the Health network in a timely manner are identified and followed through out by the WACHS Information and Communications Technology (ICT) departments in all regions.
Information and Communications Technology - Virus and Vulnerability Protection Procedure
This procedure has been developed to ensure that in all regions, the WACHS has a formal process to ensure all vendor security patches are assessed, tested and if applicable, applied and that any system not running the latest anti-virus software is fixed within a timely manner to reduce security vulnerabilities.
Information and Communications Technology Request Procedure
This document describes the procedure required to initiate an ICT request and the requirements / pathway for approval.
Information for Patients-Carers - Palliative Care Ambulatory Infusion Pump Brochure
Patient information brochure explaining the use and care of their syringe driver.
Initial Medical Management of Neutropenic Sepsis - Febrile Neutropenia in Adult Oncology Patients Procedure
This procedure provides guidance for local clinicians regarding treatment of febrile neutropenia appropriate for local (adult) patients.
Injury Management Policy
The Workers' Compensation and Injury Management Act 1981 (the Act) regulates the management of work related injuries in Western Australia. Section 155B of the Act establishes Injury management provisions, supported by a Workers' Compensation Code of Practice (Injury Management) (2005) (the Code). The Code provides a statutory framework for injury management systems and return to work programs to be established and implemented. This policy framework was developed to enable the WACHS to create a systematic approach to managing workers compensation claims and injury management processes in accordance with the requirements of the Code.
Injury Management System - Overview
This overview should be read by an injured employee as they prepare to lodge a Workers' Compensation claim.
Inland and Coastal Laundry Services Procedure - Bridgetown and Busselton
To deliver a quality laundry service, guided by Australian Standard AS 4146, which produces clean, hygienic linen in a customer focused and efficient manner.
Inpatient Flow Management Plan Procedure
This plan outlines the procedures and processes required to monitor the hospital bed capacity status 24 hours a day 7 days per week and ensure implementation of appropriate action when required.
Inpatient Leave Procedure - Goldfields Mental Health Inpatient Unit
This document sets out the process that is to be followed for all accompanied/unaccompanied leave taken by mental health inpatients.
Inpatient Personal Devices Procedure - Goldfields Mental Health Service
The use of personal devices, laptops and personal hand held devices on the mental health inpatient ward may present a hazard or distraction to the user, and the rationale for this procedure is to ensure personal device use while on the ward is both safe and secure and does not disrupt patient care and safety.
Insertion, Removal and Care of a Transvenous Pacing Wire (Floatation Catheter) Procedure - Bunbury Hospital ICU
This procedure defines the role of the healthcare staff in providing safe and appropriate healthcare to all patients requiring a temporary pacing wire (TPW) and to facilitate a smooth safe process.
Inservice Inspection, Testing and Tagging of Electrical Equipment Guideline
This guideline is part of the hazard management element of the WA Country Health Service safety management system (SMS) and seeks to ensure, as far as practicable, the safety of persons using electrical equipment within WACHS.
Integrated Clinical and Corporate Risk and Quality Improvement Management Procedure - Kimberley
The purpose of this document is to describe the integration of issues and risk management with quality improvement activities in WA Country Health Service (WACHS)-Kimberley and is intended to complement the WACHS Framework for Risk Management
Intensive Care Unit - Intra-Abdominal Pressure Measurement Guideline - Bunbury Hospital
This document defines the role of the healthcare staff in providing intra-abdominal pressure measurement safely and appropriately with minimal risk.
Intensive Care Unit Procedure - Bunbury Hospital
This document defines the role of the Level 1 Intensive Care Unit (L1 ICU) inpatient management and outlines the pathways to access the unit.The intention is to improve the interdisciplinary communications, management and care of patients requiring admission to the ICU. The process will provide a framework for balancing the competing demands of clinicians for admissions of patients to the ICU.
Interhospital Clinical Handover Form Procedure
The aim of the clinical handover process is to achieve effective, high quality communication of relevant clinical information between clinicians.
Interhospital Patient Transfer Envelope
Patient transfer envelope/checklist.
Inter-Hospital Patient Transfer Flowchart Appendix D - South West
This flowchart (Appendix D of the WACHS IHPT Policy) sets out the process for patient transfers within the South West region. Please see the EDITABLE version on the right under 'Related Documents' - 'Forms' for completion of site specific details.
Interhospital Patient Transfer of Mental Health Patients Guideline
This guideline relates to those patients being transferred for the purposes of referral, transfer and/or treatment of voluntary, referred or involuntary mental health patients.
Internal Audit Monitoring and Coordination Procedure
This procedure sets out the arrangements for the monitoring and coordination of external audits. Audits are either internal or external audits. For information on the management of 'external' audit please refer to the WA Country Health Service (WACHS) External Audit Monitoring and Coordination Procedure.
Intradermal Sterile Water Injections for Lower Back Pain in Labour Policy
This policy covers Intradermal sterile water injections (SWI) which are known to be a simple, safe, effective, non-pharmacological technique for relieving severe back during labour. The technique has been found to be effective in resolving back pain for 85% of women, and has no known side-effects.
Intradermal Sterile Water Skin Injections - Skills Assessment Checklist
This skills assessment ensures staff can safely, effectively and appropriately manage Intradermal Sterile Water Injections (SWI) in accordance with organisational and legislative requirements.
Intranet Governance Policy
This policy outlines the design and maintenance of the WACHS intranet to follow quality improvement principles and comply with legislative requirements so that communication processes are consistent throughout the health service.
Intravenous Immunoglobulin Guideline
The guideline outlines the prescribing and administration of intravenous immunoglobulins provided by the National Blood Authority. Each item has different administration and monitoring requirements which is outlined in the guideline. Direction is also given to provide standardisation of consent and documentation.
Intravenous Infusion Orders for Common Drugs in the Intensive Care Unit Guideline - Bunbury Hospital
This document MUST be restricted to ICU use (which equates to Bunbury ICU only) as this is the only site with patients of associated acuity to warrant such therapy and the unit with adequate resourcing to safely administer as recommended in the document.
Intravenous Iron Infusion Brochure
Patient information about intravenous iron infusion.
Intravenous Opioid Administration Policy
This policy outlines how patients with pain are to receive timely, effective and appropriate analgesia titrated according to response, with sufficient suitably qualified staffing to provide a safe environment during the administration of the IV opioids and in the post administration observation period.
Investigations Following Births With, or With Risk of, Adverse Neonatal Outcome Procedure - Kalgoorlie Hospital
Collection of appropriate pathology samples at the time of birth can be used to better inform clinicians and the family as to what the underlying cause of a baby's ill health might be. It is therefore important for all midwives and obstetric doctors to be aware of the situations when these samples are to be collected.

J

Job Hazard Analysis Procedure
This document provides support and advice for assessing, planning and executing moderate to high risk work activities that do not have a Safe Work Procedure. The JHA is a hazard management tool that is used to outline a safe method for completing those tasks and document how risk has been mitigated to an acceptable level to perform the task.
Journey Risk Assessment and Management Procedure - Wheatbelt Mental Health
Journey Risk Assessment and Management Procedure for all Wheatbelt Mental Health Travel.

K

Ketamine Infusion (Low Dose Intravenous Analgesia) in the Acute Care Setting Procedure - South West
This procedure sets out the indications for use, precautions, dosage and administration, side effects, management of side effects, observations and nursing implications related to the use of Ketamine infusion in the acute care Setting.
Key Control Procedure
As part of the WACHS Security Risk Management Policy, this procedure addresses key control issues, including the issuing keys and cards, key management, key audits, key registers and lost or stolen keys.
Key Register, Issuing of Keys and Proximity Cards Procedure - Denmark Hospital
This procedure provides direction for relevant staff at the Denmark Health Service to ensure risks associated with access to workplaces are effectively controlled. This also applies to any regional visiting staff or contractors requiring access to areas within the health service.
Kimberley Ambulance Service Procedure
This procedure is designed to provide those staff who will be required to work within the ambulance service, with the underpinning knowledge and appropriate skills to ensure safe and quality care provision.
Kimberley Needle and Syringe Program Procedure
This procedure outlines the provision of sterile injecting equipment, and the engagement with a high risk group to provide harm minimisation health information and referral to medical services, and the Kimberley Mental Health and Drug Services (KMHDS).

L

Learning Development Program Development Procedure
This procedure has been established to provide a structured approach for the management of WACHS Learning and Development resources and programs that are hosted within Capabiliti Learning Management System.
Levodopa Medications Poster - South West
Levodopa Medications Poster
Limited Use of Bedside Ultrasound by Midwives in Third Trimester Pregnancy Policy
The modality of Bedside Ultrasound can be used as an extension of the physical examination, potentially assisting the midwife with key patient management decisions in urgent clinical situations, where an obstetric doctor is not on site.
Limited Use of Bedside Ultrasound by Midwives Skills Assessment Checklist
Skills Application Checklist - Limited Use of Bedside Ultrasound by Midwives in Third Trimester Pregnancy.
Live Organ Donor - Travel and Accommodation Reimbursement Scheme Information Sheet for Donors
This information sheet for donors explains about the scheme which is designed to reimburse live organ donors from WA Country Health Service (WACHS) regions for some of their travel and accommodation costs when travelling for donation assessment, surgery and one post-operative visit, unless this can be done through Telehealth.
Live Organ Donor Travel and Accommodation Reimbursement Scheme Policy
This scheme is designed to reimburse live organ donors from WA Country Health Service (WACHS) regions for some of their travel and accommodation costs when travelling for donation assessment, surgery and one post-operative visit, unless this can be done through Telehealth.
Loan of Aids and Equipment by Allied Health Professionals Procedure
This document provides information on the WA Country Health Service (WACHS) provision of loan equipment to admitted and non-admitted patients, as prescribed by a WACHS allied health professional.
Local Doctor Unavailable Policy
The purpose of this policy is to ensure that patients in rural and remote communities are able to access clinically appropriate care as close to home as possible.

M

Macerator Use Procedure - Great Southern
This procedure relates to all Great Southern hospital staff and volunteers who are disposing of human waste in macerators.
Major Haemorrhage Procedure for WACHS sites WITH Blood Products
This generic procedure, based on the Massive Transfusion Protocol (MTP) provided by the National Blood Authority of Australia (NBA), needs to be modified for each site according to local practice (e.g. notify the Laboratory or Nurse manager), local Laboratory and blood test availability, local blood product availability and Royal Flying Doctor Service (RFDS) resources.
Major Haemorrhage Procedure for WACHS Sites WITHOUT Blood Products
This generic template, based on the Massive Transfusion Protocol (MTP) provided by the National Blood Authority of Australia, needs to be modified for each site according to local practice, local blood test availability and local product availability.
Malignant Spinal Cord Compression Clinical Practice Standard
This CPS has been endorsed for use by WACHS and should be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.
Management and Review of 'Did Not Wait' Patients that Present to Emergency Services Policy
To ensure the safety and treatment of all patients attending WACHS Emergency Services for treatment, this policy outlines the process of management and review for those patients who did not wait for treatment after triage and the WACHS duty of care for the presenting patient.
Management of a Complaint or Concern About the Performance of a Medical Practitioner Guideline
This guideline identifies the way in which a complaint or concern about a medical practitioner (MP) is to be handled in the WACHS. It grades a response according to the seriousness of the issues raised from a review at a local level to a formal investigation to referral to external agencies including the Medical Board.
Management of Consumers Who Decline Initial Mental Health Assessment Policy
This policy is for use in community mental health services where a consumer declines initial or follow-up assessment .
Management of Consumers Who Do Not Attend Community Mental Health Appointment Policy
This policy is for use in community mental health services where a consumer Does Not Attend (DNA) a planned appointment.
Management of Elective Surgical and Obstetric Patients with an Elevated Body Mass Index Procedure
This procedure covers all elective surgical and obstetric patients. It describes the process to ensure the safe management of obese and morbidly obese patients scheduled for elective surgery.
Management of Patients Awaiting Aged Care Services Procedure
This procedure has been developed to provide a standardised foundation for the management of inpatients in WA Country Health Service (WACHS) who no longer require acute or subacute care and are waiting in a public hospital bed for Aged Care Services. It is for all WACHS staff involved in the care and discharge planning of older patients. Aged Care Services includes Commonwealth funded permanent residential aged care, Home Care Packages (HCP) and the Transition Care Program (TCP). Young people with disabilities under the age of 65 years are also included if they require permanent or respite care in a residential aged care facility when there is no other appropriate option in the disability sector. Patients requiring residential respite care and patients of Multi-Purpose Services (MPS) are excluded.
Management of Potassium Ampoules - Albany Hospital
This procedure limits the availability of potassium ampoules and requires local guidance regarding access to these, especially outside of pharmacy hours.
Managing Risks of Hazardous Chemicals and Dangerous Goods Procedure
This procedure provides managers and staff with practical guidance on how to manage health and safety risks associated with hazardous chemicals and dangerous goods in their workplace.
Managing WorkSafe Notices Procedure
The WA Country Health Service aims to resolve all safety and health issues quickly and effectively in accordance with statutory obligations imposed by the Occupational Safety and Health Act 1984 and has developed this procedure to enable prompt effective action in the event a WorkSafe Notice (WIN) is issued by a WorkSafe inspector or a Provisional Improvement Notice (PIN) is issued by a qualified safety and health representative (SHR).
Managing WorkSafe Site Visits Procedure
The WA Country Health Service (WACHS) aims to resolve all safety and health issues promptly and effectively in accordance with statutory obligations imposed by the Occupational Safety and Health Act 1984. This procedure enables prompt effective action in the event of a site visit by a WorkSafe inspector and any issue of an Improvement Notice.
Maternal and Newborn Care Capability Framework Policy
The publication of the WACHS Maternal and Newborn Care Strategy has resulted in the WACHS maternity services policy no longer being relevant except for the maternal and newborn care capability section and relevant appendices.
Maternity and Neonatal Consultation and Referral Guideline for Clinical Service Levels
This document (formerly Appendix 4 of the WACHS Maternity and Newborn Services Policy) provides an indicative guide of the most appropriate clinical settings for women and babies with complications of pregnancy, birth, the postpartum and neonatal periods. The guide is neither an exhaustive list of possible clinical scenarios, nor is it meant to be prescriptive.
Maternity and Newborn Care Resources - EUCP Policy
This policy specifies the external maternity and newborn care policy documents that are endorsed for use in WACHS clinical practice.
Maternity Care Clinical Conflict Escalation Pathway Policy
Ths policy has been developed to ensure the appropriate channels are followed to achieve safe and timely resolution to any conflict of clinical opinion which may arise between health practitioners involved in the care of a maternity client.
Maternity High BMI and Bariatric Surgery Risk Management Policy
This policy deals specifically with the safe management of the obstetric and anaesthetic risks associated with the obese pregnant client or those with a history of bariatric surgery.
Maternity Security Procedure - Bunbury Hospital
This procedure is to look at the normal operating procedure of maternity, the increased protocols when there is an active Code Black and the protocols when patients need to be admitted outside the maternity unit.
Maternity Ward Discharge and Visiting Midwifery Service Procedure - Bunbury Hospital
The Visiting Midwifery Service (VMS) is a home visiting service for postnatal women and neonates requiring the ongoing care of a Registered Midwife. This procedure is to ensure that all women and neonates receive appropriate care and follow up postnatally for a minimum of five days postpartum upon leaving the hospital.
Maternity Ward Lift Contingency Procedure - Bunbury Hospital
This contingency plan is to be invoked in the event of both lifts being inoperative when a decision has been made that a women is required to be transported to theatre for a non-elective caesarean section.
Meal Service Procedure - Albany Acute Psychiatric Unit
This procedure aims to ensure that staff are aware that meal times can be a time of increased risk of incidents and that additional care is to be taken when preparing for and observing meal times.
Mechanical Restraint Procedure - Albany Hospital Acute Psychiatric Unit
The use of mechanical bodily restraint is governed by the Mental Health Act 1996 sections 121 - 124, however the GS Mental Health management team is adamantly opposed to the use of mechanical restraint within the authorised inpatient unit. There are always other methods to be used in the situation in which mechanical restraint might be considered. If a patient is difficult to contain, the nursing staff are to discuss with the treating psychiatrist, suitable and safe options available for containment.
Media and Communications Policy
WACHS Communications is the focal point for all contact with, and comment to the media, to ensure that we deliver a consistent and timely message to all sections of the media. This includes mainstream print, radio and television, as well as health-specific media. All media inquiries and calls from journalists must be referred to WACHS Communications.
Medical Alert Cancer Treatment
Medical Alert Cancer Treatment Form
Medical Alert Procedure - South West
This procedure details the requirements for clinical staff (doctor/nurse/midwife/pharmacist) to ensure correct and complete reporting, notification and documentation of medical alerts (adverse drug reactions, anaesthetic alerts and medical alerts). It also details the integration between the clinical process and the Health Information Management (HIM) processes that are to occur within WA Country Health Service - South West (WACHS-SW), including the review of alerts by designated relevant responsible officers. The principles of this procedure are based on the Department of Health WA Clinical Alert (Med Alert) Policy Operational Directive OD 0511/14.
Medical and Risk Alert Process Flowchart - Wheatbelt
This process has been simplified to streamline the actioning of alerts and inputting them on the PAS. All alerts are to be sent to WACHS-WBPatientAlerts@health.wa.gov.au.
Medical Credentialing and Compliance Requirements Guideline
The purpose of this guideline is to provide guidance to regional health service executives, administrative staff and medical practitioners about the responsibilities and processes for credentialing and defining a scope of clinical practice for Medical Practitioners working at WACHS sites, and to ensure that the appropriate credentialing and compliance requirements are met.
Medical Equipment Procurement Policy
The purpose of this policy is to describe the actions required to minimise these risks specific to medical equipment procurement. This policy should be used in conjunction with the relevant procurement policies issued by the State Supply Commission and Director General.
Medical Equipment Replacement Committee - Terms of Reference
The purpose of this committee is to manage the WA Country Health Service Medical Equipment Replacement Program (MERP) in accordance with the Department of Health Medical Equipment Working Party (MEWP) guidelines.
Medical Governance for Post Operative Care of Surgical Patients Procedure
The model of medical care at the Albany Hospital is a shared care model. The purpose of this procedure is to outline the medical governance arrangements for post-operative surgical patients and their continual care for the Great Southern region.
Medical Imaging - Radiation Safety Plan
This document describes the management of radiation safety at WA Country Health Service (WACHS) sites. It lists the regulatory publications, guidelines and general policies that are applicable to radiation safety and is intended to be read by any person responsible for any aspect of radiation safety across WACHS.
Medical Imaging Request Form - Goldfields
Medical Imaging Request Form
Medical Imaging Request Form - Kimberley
Medical Imaging Request Form
Medical Imaging Request Form - Midwest
Medical Imaging Request Form
Medical Imaging Request Form - Pilbara
Medical Imaging Request form for use in the Pilbara
Medical Imaging Request Form - Wheatbelt
Medical Imaging Request form for use in the Wheatbelt
Medical Imaging WA Picture Archive and Communications System Downtime Procedure
This procedure outlines the impact of a disruption or failure of WAPACS PACS/RIS and the associated workaround (downtime) procedure for key personnel to undertake to facilitate the viewing of diagnostic images performed in WACHS sites without the ability to transmit images to WAPACS for viewing.
Medical Practitioners' Manual
This information applies to all medical practitioners holding appointments or clinical privileges at WACHS facilities however they are paid, and compliance with them is a condition of the grant of clinical access.
Medical Referral and Escalation - Telephone Communication Record Procedure - Denmark Hospital
The Telephone Communication Record (TCR) must be utilised by all nursing staff to document all telephone communication with a medical officer when there is a request made for clinical review of an acute inpatient or resident in the Residential Care Unit, Blue Wren Lodge (BWL).
Medical Treatment Liability Reporting Procedure - Kimberley
This document outlines how incidents in which there is a potential for compensation or medico-legal proceedings are to be referred within the WACHS Kimberley region.
Medication Administration Policy
This policy is for application across WACHS health sites (adult and paediatric), and including hospital in the home, community health and public health settings, sub acute care, mental health and aged care facilities, and remote area nursing posts.
Medication Guideline for Direct Care Unregulated Health Workers
This document provides an outline of the required minimum standards for the involvement of unregulated health workers (UHW) in the support and/or administration of client medication. The guideline has been developed to ensure a standardised approach, safety and quality for consumers and staff.
Medication Safety for Carers of Palliative Care Patients at Home Procedure
This document outlines the processes to be undertaken to ensure medication safety for palliative carers at home.
Medication Storage Procedure - Wheatbelt
Bedside storage of medications is to be the usual practice in Wheatbelt hospitals. This procedure provides further information about how bedside medication storage is to be implemented, and the likely exceptions.
Memorandum of Understanding-Service Agreement - Template - Great Southern
This template formalises arrangements for periodic use of rooms/facilities at WACHS Great Southern sites. Please see EDITABLE versions of the MoU/SA Template and associated MoU/SA Checklist to the right of this page under 'Related Documents' / 'Forms'.
Mental Health Care in Emergency Departments and General Wards Policy
This policy provides a framework for the timely, safe and accurate assessment and care of people seeking MH care by non-MH staff within WACHS EDs and on general hospital wards, and in obtaining specialist MH care. It provides specific guidance for the assessment and care of people who present at risk of suicide.
Mental Health Clinical Supervision Guideline
WACHS strongly recommends all clinical staff, involved in the delivery of direct care to Mental Health consumers, to be engaged in a process of clinical supervision for a minimum of one hour per month. The aim is to support the clinician in their professional environment with the goal of improving clinical practice and improving patient outcomes.
Mental Health Liaison Nurse Procedure - Albany Hospital
This procedure describes the Mental Health Consultation and Liaison service that is provided by the Great Southern Mental Health Service (GSMHS) to the Great Southern Region.
Mental Health Restraint Policy
In accordance with the WA Chief Psychiatrist's Standards for Clinical Care 2015, WA Country Health Service (WACHS) is committed to working with consumers and carers to prevent, reduce and eliminate the use of restrictive practices. Early intervention, assessment, crisis management, deescalation and other alternatives to restraint are preferred interventions of choice in managing patient care and safety. WACHS recognises however that there are circumstances where restraint may be necessary to minimise imminent risk to the patient, visitors and/or staff.
Mental Health Road Transfer Procedure
Road transfer of mental health clients carries potential risks for both clients and staff and deserves an appropriate level of consideration, planning and collaboration to make the situation as safe as possible for all involved. This document sets out the process around how this is achieved for staff and clients from within the catchment area of the Great Southern Mental Health Service.
Mental Health Road Transfer Procedure - Wheatbelt Mental Health Service
Mental health clients have the right to safe transport that minimises interference with their rights, dignity and self-respect and that reduces the likelihood that they will experience the transport as a traumatic event. These rights must be balanced with the need to protect the safety of all involved and the active management of risks identified.
Mental Health Seclusion Policy
In accordance with the WA Chief Psychiatrist's Standards for Clinical Care 2015, WA Country Health Service (WACHS) is committed to working with consumers and carers to prevent, reduce and eliminate the use of restrictive practices. Early intervention, assessment, crisis management, de-escalation and other alternatives to seclusion are preferred interventions of choice in managing patient care and safety. WACHS recognises however that there are circumstances where seclusion may be necessary to minimise imminent risk to the patient, visitors and/or staff.
Mental Health Shift Coordinator Procedure - Albany Hospital Acute Psychiatric Unit
The shift coordinator is responsible for supervising, monitoring, delegating, and communicating all operational processes involving the provision of safe and effective nursing care. The shift coordinator would generally not be directly allocated patients.
Mental Health Triage and Short Term Treatment Procedure - Goldfields Mental Health Service
The Goldfields Mental Health Service is a specialist service that provides inpatient and community care to mental health patients in the Goldfields region. Triage Officers are based at the Community Mental Health Clinics in Kalgoorlie and Esperance with a regional CAMHS Triage Officer based in Kalgoorlie. This procedure outlines the role of Triage Officers within the GMHS to prioritise care based on clinical urgency/risk, and to assist consumers to access effective and appropriate support (from either GMHS or another service provider). This procedure does not apply to Emergency Triage or Disaster Triage.
Mental Health Triage Service Procedure
This document promotes easy and timely access to appropriate health services for patients experiencing mental health problems.
Microbiological Alert Process Flowchart - Wheatbelt
This process has been simplified to streamline the actioning of alerts and inputting them on the PAS. All alerts are to be sent to WACHS-WBPatientAlerts@health.wa.gov.au.
Midwife Initiated Medication Policy
A Structured Administration and Supply Arrangement (SASA) is a written direction of the WA Country Health Service (WACHS) that authorises a midwife, under Part 6 of the Medicines and Poisons Regulations 2016, to administer or supply a medicine to any patient in specified circumstances. A SASA enables midwives to administer certain medications, for specified clinical indications in accordance with endorsed clinical guidelines, without a medical prescription or order. A SASA cannot be used for Schedule 8 medicines.
Midwife Mentoring Policy
This document is aimed to define the role of mentoring and address mentoring needs of midwives within the WACHS.
Missing Aged Care Resident Procedure
A resident is considered missing when they are absent and the facility is unaware of any reasons for the absence. A missing resident may also include a resident who has not returned from leave at the specified time. This procedure outlines the processes to be followed and is to be read in conjunction with the WACHS Consumer Identification Policy for Community Health Settings and Residential Aged Care.
Missing or Suspected Missing Inpatient Procedure
The WA Country Health Service (WACHS) is committed to providing for the safety and wellbeing of patients and to minimise potential harm to the public. WACHS owes a duty of care to all patients admitted to any of its facilities. This duty includes the responsibility to protect and care for people who because of illness, may come to harm by leaving a health site and potentially wander off into unfamiliar surroundings. For guidance on missing or suspected missing mental health inpatients refer to the MP 0012/16 Missing Person Policy - WA Public Mental Health Services.
Missing or Suspected Missing Patient Procedure
This procedure outlines the actions necessary should a patient be missing from an inpatient area.
Mobile Device Policy
The purpose of this policy is to ensure WA Country Health Service mobile device assets are uniformly and appropriately procured, provisioned and managed, to implement a uniform and consistent approach to device security and to ensure that all users of WA Country Health Service mobile devices are aware of their responsibilities.
Monitoring Internal and External Audit Recommendations Procedure - Wheatbelt
Internal and external audits are regularly undertaken across the WA Country Health Service - Wheatbelt as an independent, objective assurance activity designed to add value, improve the region's operations, ensures the region is accountable, continues to provide a quality service and is financially responsible. Appropriate governance activities provide assurance to the Wheatbelt Audit and Risk Sub-Committee that open audit recommendations are being actively monitored, actioned and completed.
Monthly Index for Medical Specialities (MIMS) - EUCP Policy
WACHS has endorsed MIMS for use in clinical practice.
Mortuary Release Document
This document ensures the Funeral Director (or their employee) requesting the deceased holds a current Funeral Directors Licence (FDL) prior to the release of the deceased.
Motor Vehicle Fleet - Driver and Management Policy
The objective of this policy is to provide the foundation for improved management of the WACHS passenger and light commercial fleet, ensuring optimal and effective fleet management practices are in place.
Motor Vehicle Fleet Senior Officer Vehicle Scheme Procedure
This procedure identifies the minimum requirements for participation in the Senior Officer Vehicle Scheme (SOVS), in compliance with the WA Government Fleet Policy and Guidelines (WAGPFG)
MR 170.8 WA Agitation and Arousal PRN Chart
MR 170.8 WA Agitation and Arousal PRN Chart
MR 170.9 WA Intramuscular Long-Acting Injection Chart (Depot Antipsychotic)
MR 170.9 WA Intramuscular Long-Acting Injection Chart (Depot Antipsychotic)
MR CC Alert 1 WACHS Chronic Condition Alert Notification Form
Chronic Condition Alert form for use by clinical staff as a prompt to identify eligible patients with a chronic condition, and to activate appropriate care pathways, inform discharge planning and referral to primary health services for self-management and support.
MR CH66A WACHS Child Health Fluoride Varnish Oral Health Assessment and Consent Form
This form supports the WACHS Administration of Fluoride Varnish by Non-Dental Practitioners Policy by providing both the checklist for oral health assessment and the consent and administration sign off requirements.
MR Child at Risk Alert 1 - WACHS Child at Risk Alert Notification Form
WACHS Child at Risk Alert Notification Form
MR0.0 WACHS Risk Assessment for Provision of Unplanned Solo Services
Risk assessment for the provision of unplanned solo services.
MR1 WACHS Emergency Department Notes
Emergency Department MR1 form. Strictly orderable - iProc 134232T
MR101 Laboratory Reports
Laboratory Reports - iProc Order Number 91665C
MR111 WACHS Nursing Admission, Screening and Assessment Tool - Adults
Nursing Admission, Screening and Assessment Tool - Adults Strictly Iproc order only - number 188021A
MR111P WACHS Paediatric Nursing Admission - Discharge Assessment Form
Paediatric Nursing Admission / Discharge Assessment Form. iProc Order No. 186874M
MR115 WACHS Paediatric Short Stay Medical Admission
Paediatric Short Stay Medical Admission
MR12 WACHS Emergency Department Procedural Sedation Record
MR12 WACHS Emergency Department Procedural Sedation Record
MR120 WACHS Adult Nursing Care Plan
Adult Nursing Care Plan - 'My Care Plan' Strictly Iproc order only - number 188022B
MR120P WACHS Paediatric Nursing Care Plan
Paediatric Nursing Care Plan. iProc Order No. 186875N
MR122 WACHS Wound Assessment and Management Plan
MR122 WACHS Wound Assessment and Management Plan - IProc order number: 186611B
MR124 WACHS Braden Scale and Pressure Injury Risk Assessment
Braden Scale and Pressure Injury Risk Assessment
MR124A WACHS Glamorgan Paediatric and Neonatal Pressure Injury Risk Assessment
This is a paediatric and neonatal pressure injury Risk assessment form. iProc Order No. 105274E
MR124B WACHS Comprehensive Skin Assessment
Comprehensive Skin Assessment
MR129 WACHS Chest Drain Assessment and Observation Chart
Chest drain assessment and observation chart.
MR12A WACHS Sedation Assessment Tool
MR12A WACHS Sedation Assessment Tool (reviewed 02/08/2019 - no changes required)
MR137 WACHS Portable Ventilation Order and Observation Chart
WACHS MR137 Portable Ventilation Order and Observation Chart
MR140 WACHS Medical Emergency Response - Code Blue Record
WACHS Medical Emergency Response (MER) / Code Blue Medical Record form.
MR140A Adult Observation and Response Chart (A-ORC)
MR140A Adult Observation and Response Chart (A-ORC). IProc Order Number: 151847C
MR140B Maternal Observation and Response Chart (M-ORC)
MR140B Maternal Observation and Response Chart (M-ORC). IProc Order Number: 161837T
MR140C Additional Maternal Observation Chart
MR140C Additional Maternal Observation Chart IProc Order Number: 164481G
MR140D Newborn Observation and Response Chart (N-ORC)
MR140D Newborn Observation and Response Chart (N-ORC). IProc Order Number: 164666E
MR140E Paediatric Observation and Response Chart (P-ORC - under 3 months)
MR140E Paediatric Observation and Response Chart (P-ORC - under 3 months). IProc Order Number: 164667F
MR140F Paediatric Observation and Response Chart (P-ORC - 3-12 months)
MR140F Paediatric Observation and Response Chart (P-ORC - 3-12 months). IProc Order Number: 164668G
MR140G Paediatric Observation and Response Chart (P-ORC - 1-4 years)
MR140G Paediatric Observation and Response Chart (P-ORC - 1-4 years). IProc Order Number: 164669H
MR140H Paediatric Observation and Response Chart (P-ORC - 5-11 years)
MR140H Paediatric Observation and Response Chart (P-ORC - 5-11 years). IProc Order Number: 164670J
MR140I Paediatric Observation and Response Chart (P-ORC - 12+ years)
MR140I Paediatric Observation and Response Chart (P-ORC - 12+ years). IProc Order Number: 164671K
MR140S WACHS Snakebite Observation Chart
MR140S WACHS Snakebite Observation Chart
MR141 WACHS CARE Call Clinical Review Record
The CARE Call Clinical Review Record is to be completed and placed in the patient's medical record as soon as practical following a CARE Call. Forward a completed copy to the appropriate Regional Safety and Quality Team and to WACHS Area Office Safety and Quality at wachs.safetyqualityperformance@health.wa.gov.au
MR142 WACHS Neonatal - Paediatric Respiratory Observation Chart
Neonatal / Paediatric Respiratory Observation Chart. iProc Order No. 186876P
MR144 WACHS Fluid Balance Work Sheet
Fluid Balance Work Sheet - iProc Order Number 91689E
MR144C WACHS Dietetics - Food Intake Chart
Standardised food intake chart for WACHS health facilities.
MR144D WACHS Neonatal - Paediatric Enteral Feeding Prescription
Neonatal / Paediatric Enteral Feeding Prescription
MR144E WACHS Bowel Chart
iProc order number is 191966C
MR144P WACHS Neonatal - Paediatric Fluid Balance Worksheet
Neonatal / Paediatric Fluid Balance Worksheet. iProc Order No. 186877R
MR147 WACHS Adult Neurological Observation Chart
MR147 Adult Neurological Observation Chart
MR147A WACHS Paediatric Neurological Observations Chart
Paediatric Neurological Observations Chart. iProc Order No. 186878T
MR149 WACHS Neurovascular Observation Chart
The MR149 WACHS Neurovascular Observation Chart is to be utilised for all patients (adults and paediatrics) requiring neurovascular observations and assessment in WACHS.
MR156A WACHS Insulin Subcutaneous Order and Blood Glucose Record - Adult Form
WACHS Insulin Subcutaneous Order and Blood Glucose Record for Adults. Order from iproc on 189143Am
MR156B WACHS Obstetric Subcutaneous Insulin Order and Blood Glucose Record
Track and trigger blood glucose monitoring, ranges within this chart are in accordance with obstetric ranges rather than general population ranges allowing for appropriate identification of hyperglycaemia in pregnancy and management.
MR157A WACHS Insulin Infusion Order Chart
This form is for ordering and administration of intravenous Insulin Infusions. These infusions are required to have a concurrent glucose infusion.
MR169A WACHS Community Aged Care Medication Order
Community Aged Care Medication Order form (only to be used with Community clients receiving home services)
MR169C WACHS Community Aged Care Medication Record
Community Aged Care Medication Record (only to be used with Community clients receiving home services)
MR170.1 Medication History and Management Plan
Medication History and Management Plan - iProc Order Number 168563J
MR170.1.1 WACHS Medication History and Reconciliation Record
Medication History and Reconciliation Record - iProc Order Number 190301C
MR170.2 WACHS Epidural-Spinal Prescription and Additional Observations Chart
Epidural/Spinal Prescription and Additional Observations Chart
MR170.3 WACHS Epidural-Spinal Morphine Record
MR170.3 Intrathecal Morphine Record
MR170.4 WA Adult Clozapine Initiation and Titration Chart
This chart is mandated for restricted use in mental health units as this is the only setting where clozapine will be commenced and monitored under the direct supervision of a psychiatrist.
MR170.4.1 WACHS Clozapine Monitoring Form
This form supports the effective monitoring of clozapine patients in the maintenance phase of clozapine (beyond 18 weeks) ensuring clinical consistency, optimal patient safety outcomes and reduced risk of harm.
MR170.5 WACHS PCIA-IV Opioid Infusion Prescription and Additional Observation Chart
PCIA-IV Opioid Infusion Prescription and Additional Observation Chart
MR170.6 WACHS PCIA-IV Opioid Infusion Continuation Sheet
PCIA-IV Opioid Infusion Continuation Sheet
MR170.7 WACHS Ophthalmic Surgery Medication Chart
Medication chart for use in opthalmic surgery (only). iProc order number 190430R
MR170A WA Hospital Medication Chart - Adult Short Stay
MR170A WA Hospital Medication Chart - Adult Short Stay - iProc Order Number 137558J
MR170C Anticoagulant Medication Chart
WACHS version - MR170C Anticoagulant Medication Chart - iProc Order Number 153725N
MR170D National Inpatient Medication Chart - Paediatric Short Stay
National Inpatient Medication Chart - Paediatric Short Stay. iProc Order Number 154621G
MR170E National Inpatient Medication Chart - Paediatric Long Stay
National Inpatient Medication Chart - Paediatric Long Stay. iProc Order Number 154620F
MR170H WACHS Continuous Subcutaneous Infusion Chart
Continuous Subcutaneous Infusion Chart - Medical Records Form MR170H
MR171 WA Hospital Medication Chart - Adult Long Stay
MR171 WA Hospital Medication Chart - Adult Long Stay - iProc Order Number 153749A
MR172 WACHS Tenecteplase Kit
Strictly orderable - iProc Order Number 188024E. MR172 Tenecteplase Kit which contains: Cardiac Thrombolysis - Tenecteplase Patient Information Sheet MR172A WACHS Tenecteplaxe Contraindication Checklist MR172B WACHS Tenecteplase Administration Checklist
MR173A WACHS Specialised Medication - Infliximab Pre-Infusion Checklist
Infliximab Pre-Infusion checklist
MR173B WACHS Specialised Medication - Natalizumab Pre-Infusion Checklist
Specialised Medication - Natalizumab Pre-Infusion Checklist
MR173c WACHS Specialised Medication - Iron Pre Infusion-Consent Checklist
Iron Pre Infusion-Consent Checklist
MR173D WACHS Specialised Medication - Rituximab Pre-Infusion Checklist
Rituximab Pre-Infusion Checklist
MR173E Specialised Medication - Abatacept Pre-Infusion Checklist
This checklist must be used in conjunction with the associated mandatory Specialised Medication - Abatacept for ADULT Patients Guideline
MR173F WACHS Specialised Medication - Tocilizumab Pre-Infusion Checklist
This checklist must be used in conjunction with the associated mandatory Specialised Medication - Tocilizumab Guideline
MR175A WACHS Intravenous Blood Transfusion and Blood Product Treatment Order Chart
This checklist is to be completed prior to blood transfusion, and is the responsibility of the registered nurse administering the blood transfusion.
MR176 Intravenous Fluid Treatment
Intravenous Fluid Treatment chart - iProc Order Number 91729A
MR176P WACHS Neonatal - Paediatric Intravenous Fluid Treatment Form
Neonatal / Paediatric Intravenous Fluid Treatment Form. iProc Order No. 186879W
MR179 WACHS Peripheral Intravenous Cannula Observation Record
MR179 WACHS Peripheral Intravenous Cannula Observation Record
MR179A WACHS Central Venous Access Device (CVAD) Insertion and Assessment Record
Central Venous Access Device (CVAD) Insertion and Assessment Record
MR179B WACHS Central Venous Access Device (CVAD) Insertion Site Assessment Continuation Sheet
Central Venous Access Device (CVAD) Insertion Site Assessment Continuation Sheet
MR179C WACHS CVAD Access-Dressings Continuation Sheet
CVAD Access/Dressings Continuation Sheet
MR184 WACHS Inter-hospital Clinical Handover Form
The intent of this form is to avoid duplication of information and possible transcribing errors and to remain predominantly free-text with guidance to minimum data set. This is not an exhaustive list of required information, and additional pages may be required, as well as the inclusion of supporting documentation and clinical forms i.e. MR170 NIMC Medication Charts, and Observation Charts.
MR184A WACHS Resident Handover
This Resident Handover form serves a dual hand-over function as it accompanies the resident when they are transferred to and from an acute area (ED or ward). This form is to be printed double sided with both pages completed.
MR184C WACHS Interhospital Transfer Maternal Form
MR184C WACHS Interhospital Transfer Maternity and Neonates Form
MR184P Interhospital Transfer Neonatal Paediatric
Effective handover is vital in protecting patient safety. Both neonates and paediatrics are specialist areas requiring additional considerations prior to transfer and in handover of care. This document is designed to ensure all relevant clinical information has been considered and handed over appropriately.
MR1A WACHS Emergency Department Continuation Notes
MR1 Emergency Department Notes - continuation pages. Strictly orderable form - iProcure order number 168320C
MR1B WACHS Emergency Chest Pain Kit
Strictly orderable - iProc Order number 149007B. MR172 Tenecteplase Kit which contains - MR1B Emergency Chest Pain Assessment and MR1B ACS Guide inserted in the middle.
MR1C WACHS Adult Sepsis Pathway
MR1C WACHS Adult Sepsis Pathway
MR1EL WACHS Electronic Emergency Department Notes (WebPAS only)
Electronic (WebPAS only) version of the MR1 WACHS Emergency Department Notes. Strictly orderable form - iProcure order number 167739Y
MR2 WACHS Emergency Department Trauma Notes
This is the complete WACHS Emergency Department Trauma Record. iProc Order Number: 187075H
MR20 Request for Admission-Inclusion on Waiting List
Request for Admission / Inclusion on Waiting List form - iProc Order Number 161838W
MR23 Mental Health Cultural Information Gathering Tool
Form to gather information and enable culturally safe practice for Aboriginal consumers and their carers in outpatient and inpatient settings.
MR25 Medical Discharge Summary
Medical Discharge Summary - iProc Order Number 89345D
MR29 WACHS Referral Record and Leaving Hospital Checklist - Adults
Referral Record and Leaving Hospital Checklist - Adults Strictly Iproc order only - number 188023C
MR3 SARC Emergency Care - History and Checklist
This formfacilitates the appropriate clinical care and management for sexual assault clients in our Emergency Departments and directly links in with the State SARC supports. In the event of alleged/suspected sexual assault, contact Sexual Assault Referral Centre (SARC) ASAP for advice on sample collection and storage. Phone (08) 6458 1828 (24 hours/7days)
MR30A Patient Consent to Treatment or Investigation
Patient Consent to Treatment or Investigation form - iProc Order Number 139750H
MR30AA WACHS Patient Consent to a Chaperone Form
This form is to be completed giving due consideration to the 'Consent to Treatment Policy for the Western Australian Health System'. iProc order number 190447R
MR30B Consent for a Minor Requiring Parenteral-Guardian Approval for Treatment or Investigation
Consent for a Minor Requiring Parenteral-Guardian Approval for Treatment or Investigation - iProc Order Number 139751J
MR30C Adults Unable to Consent to Treatment or Investigation
Adults Unable to Consent to Treatment or Investigation - Print as needed
MR30D Patient Consent to Anaesthesia - General or Regional
Patient Consent to Anaesthesia - General or Regional - Order from iProc on 161836R
MR30F Authorisation to Proceed with Surgery on a Patient Without a Valid Consent Form
Authorisation to Proceed with Surgery on a Patient Without a Valid Consent Form - Print as needed
MR30G WACHS Consent to Blood Products
This consent form is to be used for infusion of: Packed Red Blood Cells (PRBC), Platelets, Fresh Frozen Plasma (FFP), cryoprecipitate (cryo) and / or other.
MR30H WACHS Release of Liability - Refusal of Blood Products
This form is for the documentation of a patient's choice to refuse blood products, and/or certain products that are derived from blood and/or certain types of procedures involving the administration of blood.
MR30L WACHS Open Disclosure Discussion Record
MR30L WACHS Open Disclosure Discussion Record
MR30M WACHS Consent for Induction of Labour
MR30M WACHS Consent for Induction of Labour
MR35B WACHS Patient-Resident Identity Form
MR35B WACHS Patient/Resident Identity Form
MR36 WACHS Discharge Against Medical Advice Form
Any person who wishes to leave the hospital against medical advice is to be requested to sign a written declaration (MR36 WACHS Discharge Against Medical Advice form) that he or she is leaving the hospital against medical advice.
MR37A WACHS Death In Hospital Form
This form (along with the WACHS Review of Death Procedure) assist health practitioners to navigate the mandatory and statutory obligations that arise following the death of an inpatient.
MR39 WACHS Not for Cardiopulmonary Resuscitation Form
MR39 Not for Cardiopulmonary Resuscitatio (NFR) form which incorporates guidelines for the use and completion of the form.
MR3a WACHS-SW Security Surveillance Activation Form
Security Surveillance Activation form
MR3b WACHS-SW Security Surveillance Report
Security Surveillance Report
MR42 WACHS Older Patient Initiative Risk Screen
MR42 WACHS Older Patient Initiative Risk Screen
MR42A WACHS Older Patient Initiative Follow Up Assessment
Older Patient Initiative - Follow Up Assessment
MR42B WACHS TeleGeriatric PreClinic Assessment
MR42B WACHS TeleGeriatric PreClinic Assessment
MR42C WACHS Abuse of the Older Person Report
MR42C WACHS Abuse of the Older Person Report
MR46 WACHS Suicide Risk Assessment and Safety Plan
MR46 WACHS Suicide Risk Assessment and Safety Plan
MR5 Outpatient Notes
Outpatient Notes - iProc Order Number 89342A
MR521 WACHS Falls Risk Assessment and Management Plan (FRAMP)
The FRAMP is a tool to guide and document falls risk screening, risk assessment, minimum and individualised interventions for patients in compliance with Operational Directive OD 0579/14 Falls Risk Assessment and Management Plan (FRAMP). iProc Order Number 154600B
MR521P WACHS Paediatric Falls Risk Assessment Tool
Paediatric Falls Risk Assessment Tool. iProc Order No. 186880X
MR55A Integrated Progress Notes
Integrated Progress Notes - iProc Order Number 89368E
MR59 WACHS Cancer Coordination Admission Form
Cancer Coordination Admission Form
MR59A WACHS Consent to Cancer Treatment
Consent to Cancer Treatment Form
MR59B WACHS Cancer My Education Checklist
Cancer - My Education Checklist
MR59C WACHS Cancer Nursing Assessment and Care Plan
Cancer - Nursing Assessment and Care Plan
MR59D WACHS Cancer Treatment Infusion Observation Chart
Cancer - Treatment Infusion Observation Chart
MR59E WACHS Cancer Services Continuation Sheet
Cancer Services - Continuation Sheet
MR60.1.1 WACHS Dietetics - Inpatient Assessment
WACHS Dietetics - Inpatient Assessment form
MR60.1.10 WACHS Adult Enteral Feeding Form
Dietetics - Adult Enteral Feeding
MR60.1.11 WACHS Adult Parenteral Nutrition Form
Parenteral Nutrition (PN) support refers to the delivery of intravenous nutrition formula into the blood stream. PN is considered only when it is not possible to meet an individual's nutritional needs by enteral or oral route. Prescribing PN requires special considerations by Dietitians, Pharmacists and Medical Officers. Hence, this form is for completion by these health professionals only to ensure the appropriate formula, rates and additives are prescribed for the patient.
MR60.1.12 WACHS Oral Nutrition Support Chart
MR60.1.12 WACHS Oral Nutrition Support Chart
MR60.1.13 WACHS Dietetics Special Diet Form
Dietitians often need to provide special tailored meal plans for admitted patients to ensure the diet provided meets their nutritional needs. This form will allow Dietitians to document special diets/ meal plans on a medical record form to be filed with relevant documentation for the patient's admission. This form is to be used by catering services to provide the requested meal plan.
MR60.1.2 WACHS Dietetics - Outpatient Assessment
Dietetics - Outpatient Assessment form
MR60.1.3 WACHS Dietetics - Paediatric Nutrition Assessment
Dietetics - Paediatric Nutrition Assessment Form
MR60.1.4 WACHS Dietetics - Diet History
Dietetics - Diet History Form
MR60.1.5 WACHS Malnutrition Screening Tool
WACHS Malnutrition Screening Tool
MR60.1.6 WACHS Dietetics - Subjective Global Assessment
WACHS Dietetics - Subjective Global Assessment Form
MR60.1.7 WACHS Dietetics - Patient Generated Subjective Global Assessment (PG-SGA) Tool
This tool is for use by dietitians for assessing malnutrition in patients.
MR60.1.8 WACHS Mini Nutrition Assessment - Short Form (MNA-SF)
This is the evidence based recommenced screening tool for malnutrition in residential aged care.
MR60.1.9 WACHS Paediatric Nutrition Screening Tool
This tool is used for the nutritional screening of paediatric patients. iProc Order No. 186873K
MR61.1.1 WACHS OT - Initial Assessment Form
This form is used for initial OT assessment in both community (outpatient) and inpatient settings.
MR61.1.10 WACHS OT Showering and Dressing Assessment Form
This form is to enable standardisation of reporting when conducting Shower and Dressing Assessments.
MR61.1.2 WACHS OT - Home Assessment (Short) Form
OT Home Assessment (Short) Form
MR61.1.3 WACHS OT - Home Assessment (Long) Form
OT Home Assessment (Long) Form
MR61.1.4 WACHS OT - Hand Assessment (Short) Form
OT Hand Assessment (Short) Form
MR61.1.5 WACHS OT - Hand Assessment (Long) Form
OT Hand Assessment (Long) Form
MR61.1.7 WACHS OT - Initial Neurological Assessment
OT Initial Neurological Assessment
MR61.1.8 WACHS Activities of Daily Living Assessment Form
MR61.1.8 WACHS Activities of Daily Living Assessment Form
MR61.1.9 WACHS OT Kitchen Skills Assessment Form
MR61.1.9 WACHS OT Kitchen Skills Assessment Form
MR61.3 WACHS Modified Lawtons Instrumental ADL Assessment
Modified Lawtons Instumental ADL Assessment
MR62.16 WACHS Physiotherapy - Pelvic Pain and Continence Assessment
Physio - Pelvic Pain and Continence
MR62.17 WACHS Physiotherapy - Rectus Abdominus Diastasis Assessment
Physio - Rectus Abdominus Diastasis Assessment
MR62.18 WACHS Physiotherapy - Post-natal Breast Assessment
Physio - Post-natal Breast Assessment
MR62.18.1 WACHS Physiotherapy Post-natal Assessment
Physiotherapy Post-natal Assessment form
MR62.19 WACHS Physiotherapy - Male Continence Assessment
MR 62.19 WACHS - Male Continence assessment
MR62.20 WACHS Physiotherapy - Respiratory Assessment
MR62.20 WACHS - Respiratory Assessment
MR62.24 WACHS Physiotherapy - Vestibular Assessment
Physiotherapy - Vestibular Assessment Oculomotor Examination
MR62.25 WACHS Cardiac Rehabilitation Assessment
Cardiac Rehabilitation Assessment Form
MR62.26 WACHS Musculoskeletal Assessment
Musculoskeletal Assessment Form
MR62.3 WACHS Physiotherapy Berg Balance and Modified Balance Scale
Physio - Berg Balance and Modified Balance Scale
MR62.4 WACHS Physiotherapy De Morton Mobility Index
Physio - De Morton Mobility Index
MR62.5 WACHS Physiotherapy Torticollis and Plagiocephaly Assessment
WACHS Physiotherapy Torticollis and Plagiocephaly Assessment
MR62.6 WACHS Physiotherapy Toe Walker Assessment
Physiotherapy Toe Walker Assessment form
MR62.9 WACHS Physiotherapy - 6 Minute Walk Test
Physio - 6 Minute Walk Test
MR62C WACHS Physiotherapy Long Stroke Assessment
Physio - Long Stroke Assessment
MR62D WACHS Physiotherapy Short Stroke Assessment
Physio - Short Stroke Assessment
MR62F WACHS National Institutes of Health Stroke Score (NIHSS)
MR62F WACHS National Institues of Health Stroke Score (NIHSS)
MR63.1 WACHS Podiatric - New Patient History Form
This MR form is for recording new podiatry patient history
MR63.2 WACHS Podiatric - Neurovascular Foot Assessment
Neurovascular Foot Assessment form.
MR63.3 WACHS Podiatric - Foot Ulcer Assessment
Foot Ulcer Assessment form.
MR63.4 WACHS Podiatric - Minor Surgery Assessment
Podiatric Minor Surgery Assessment form.
MR64A WACHS Speech Pathology Adult Swallow Assessment
This form is used (primarily for and by speech pathologists) when carrying out adult swallow assessments.
MR64B Dysphagia Screening Tool (Royal Brisbane Women's Hospital (RBWH))
This MR form supports completion of the Dysphagia Screening in line with the WACHS Adult Dysphagia Screening and Assessment Clinical Practice Standard and is only to be completed by staff who have undertaken training.
MR64C WACHS Speech Pathology Voice Assessment
MR64C WACHS Speech Pathology Voice Assessment
MR64D WACHS Speech Pathology - Parkinson's Disease Assessment Form - Cranial Nerve Examination
Speech Pathology - Parkinson s Disease Assessment Form - Cranial Nerve Examination
MR64E WACHS Speech Pathology - Parkinson's Disease Assessment Form - Oral Motor Assessment
Speech Pathology - Parkinson's Disease Assessment Form - Oral Motor Assessment
MR65.1 WACHS Social Work Assessment Form
MR65.1 WACHS Social Work Assessment Form
MR659 WACHS Renal Services Referral Form
WACHS Renal Services Referral Form
MR659.1 WACHS Renal Education and Care Plan
WACHS Renal Education and Care Plan
MR66 WACHS Clinical Handover (Allied Health) Form
This is a clinical handover tool for Allied Health only.
MR66.1 WACHS Geriatric Depression Scale
WACHS Geriatric Depression Scale
MR66.10 WACHS Functional Independence Measure
WACHS Functional Independence Measure
MR66.10.1 WACHS Non-Acute Resource Utilisation Group - Activities of Daily Living (RUG-ADL) Assessment
All episodes of qualified non-acute care must have a formal assessment of functional ability using this Resource Utilisation Group - Activities of Daily Living (RUG-ADL) clinical assessment tool. The tool measures the level of functional dependence of a patient for four activities of daily living and provides an indication of what a person actually does, rather than what they are capable of doing.
MR66.10.2 WACHS Awaiting Aged Care Services Transition Plan
MR66.10.2 WACHS Awaiting Aged Care Services Transition Plan
MR66.11 WACHS Kimberley Indigenous Cognitive Assessment - Remote Living
WACHS Kimberley Indigenous Cognitive Assessment - Remote Living
MR66.12 WACHS Kimberley Indigenous Cognitive Assessment - Short Cognitive Screen
WACHS Kimberley Indigenous Cognitive Assessment - Short Cognitive Screen
MR66.13 WACHS Kimberley Indigenous Cognitive Assessment - Regional-Urban
WACHS Kimberley Indigenous Cognitive Assessment - Regional-Urban
MR66.14 WACHS Kimberley Indigenous Cognitive Assessment - Depression Scale
WACHS Kimberley Indigenous Cognitive Assessment - Depression Scale
MR66.15 WACHS Bladder Diary
Bladder Diary Form
MR66.16 WACHS Multidisciplinary Pre-Operative Assessment
Multidisciplinary Pre-Operative Assessment Form
MR66.17 WACHS 4A TEST Rapid Assessment Test for Delirium
Rapid Assessment Test for delirium.
MR66.18 WACHS Multidisciplinary Lymphoedema Assessment Form
MR66.18 WACHS Multidisciplinary Lymphoedema Assessment Form
MR66.2 WACHS Cornel Scale for Depression in Dementia
WACHS Cornel Scale for Depression in Dementia
MR66.3 WACHS Mini Mental State Examination
Mini Mental State Examination form.
MR66.4 WACHS Abbreviated Mental Test Score
WACHS Abbreviated Mental Test Score
MR66.5 WACHS Cognistat Summary Report
WACHS Cognistat Summary Report
MR66.6 WACHS Montreal Cognitive Assessment - Test 1
WACHS Montreal Cognitive Assessment - Test 1
MR66.6.1 WACHS Montreal Cognitive Assessment - Test 2
WACHS Montreal Cognitive Assessment - Test 2
MR66.6.2 WACHS Montreal Cognitive Assessment - Test 3
WACHS Montreal Cognitive Assessment - Test 3
MR66.6.3 WACHS Montreal Cognitive Assessment - Blind
The Montreal Cognitive Assessment (MoCA) is a cognitive screening test designed to assist Health Professionals in the detection of mild cognitive impairment. The standard format of is available MR format (MR 66.6, MR 66.6.1, MR 66.6.2). Two additional formats of the MoCA have now been added: (1) MoCA Test Blind - version of MoCA without the visual elements (2) MoCA Basic - version of the MoCA for people who are illiterate or with low education.
MR66.6.4 WACHS Montreal Cognitive Assessment - Basic
The Montreal Cognitive Assessment (MoCA) is a cognitive screening test designed to assist Health Professionals in the detection of mild cognitive impairment. The standard format of is available MR format (MR 66.6, MR 66.6.1, MR 66.6.2). Two additional formats of the MoCA have now been added: (1) MoCA Test Blind - version of MoCA without the visual elements (2) MoCA Basic - version of the MoCA for people who are illiterate or with low education
MR66.7 WACHS Cognitive Assessment of Minnesota - Summary
WACHS Cognitive Assessment of Minnesota - Summary
MR66.8 WACHS Rowlands Universal Dementia Assessment Scale
WACHS Rowlands Universal Dementia Assessment Scale
MR66.9 WACHS Modified Barthel Index
WACHS Modified Barthel Index
MR70 WACHS Antenatal Booking Form
Antenatal Booking Form. iProc Order Number 189004W
MR70a WACHS Antenatal Inpatient Care Plan
This document provides a standardised inpatient antenatal care plan that ensures midwifery care aligns with the KEMH clinical guidelines for antenatal inpatient admission. This is a low volume use form that is to be printed on hospital site as required.
MR70B WACHS Rh D Immunoglobulin (Anti D) Record
A more robust patient consent section has been added. Written consent to be only completed for the first administration and verbal consent for following administrations if required. Initial instructions to remain at top of first page and repeated instructions prior to each administration removed. Tick boxes added to 'Indications' section and 'Comments' section with free text.
MR70C Pregnancy Instruction Sheet
This document is designed to ensure the midwife providing antenatal care identifies all risk factors and refers the woman to the appropriate services. t ensures that the risk assessment is completed on a umber of ocasions throughout her pregnancy. It will also aid in the development of a documented antenatal, intrapartum and postnatal plan of care based upon the identified risk factors.
MR71 WACHS Labour and Birth Summary
Labour and Birth Summary. iProc Order Number 189005X
MR71A WACHS Labour and Birth Summary - Addendum Multiple Births
Labour and Birth Summary - Addendum Multiple Births
MR72 WACHS Partogram Form
This form is for use at all WACHS Maternity sites. Order via iProc UCN 181391A
MR72A WACHS Primary Post Partum Haemorrhage Record
Primary Post -Partum Haemorrhage Record
MR72B WACHS Operative Vaginal Delivery Record
MR 72B WACHS Operative Vaginal Delivery Record
MR72C WACHS Shoulder Dystocia Record
Shoulder Dystocia Record form
MR72D WACHS Cord Prolapse Record
MR72D WACHS Cord Prolapse Record
MR73A WACHS Maternity High BMI-Bariatric Surgery Risk Management Tool
Maternity High BMI-Bariatric Surgery Risk Management Tool
MR75 WACHS Newborn Care Plan
This form is for use at all WACHS Maternity sites. Stictly orderable form only - via iProc UCN 177584B.
MR75A WACHS Newborn Care Pathway - Feeding Chart Addendum
This form is an addendum - page 5 of the MR75 WACHS Newborn Care Plan (to support the requirement for any additional single sheet feeding charts for longer stay babies).
MR75AA WACHS Newborn Care Plan Continuation Sheet
This is a continuation sheet for the MR75 Newborn Care Plan
MR75B WACHS Newborn Medical Emergency Response (MER) Record
This form is for use in Newborn Medical Emergency Responses
MR76 WACHS Breastfeeding Management Plan
This form is designed to support the staff to work with the woman to design a breastfeeding plan to ensure consistency in the advice provided when managing breastfeeding issues. It also ensures advice provided is in line with latest evidence based practice and KEMH guidelines.
MR8 WACHS Maternal Fetal Assessment Admission
Maternal Fetal Assessment Admission chart. iProc Order Number 89343B
MR80 WACHS Vaginal Birth Care Plan
Vaginal Birth Care Plan. iProc Order Number 143833M
MR80A WACHS Maternity Inpatient Risk Assessment
Order via Iproc UCN 182499E
MR81 WACHS Caesarean Postnatal Care Plan
WACHS Caesarean Postnatal Care Plan
MR82 WACHS Perinatal Loss Care Plan (Less than 20 weeks gestation)
MR82 WACHS Perinatal Loss Care Plan (Less than 20 weeks gestation)
MR82A WACHS Perinatal Loss Care Plan (More than 20 weeks gestation)
MR82A WACHS Perinatal Loss Care Plan (More than 20 weeks gestation)
MR85 WACHS Boys Fenton Preterm Growth Charts
Boys Fenton Preterm Growth Charts
MR85A WACHS Girls Fenton Preterm Growth Charts
Girls Fenton Preterm Growth Charts
MR86 WACHS Boys Growth Chart Birth to 2 years
Boys Growth Chart Birth to 2 years
MR86A WACHS Girls Growth Chart Birth to 2 years
Girls Growth Chart Birth to 2 years
MR87 WACHS Boys 2-18 years Growth Chart
Boys 2-18 years Growth Chart
MR87A WACHS Girls 2-18 years Growth Chart
Girls 2-18 years Growth Chart
MR8A WACHS Record of Telephone Contact-Advice - Obstetrics
Record of Telephone Contact / Advice - Obstetrics. iProc Order Number 167633R
MR8B National Woman-Held Pregnancy Record
This nationally consistent client-held pregnancy record, is for use by all Australian women to ensure reduction in local variations in service and practice. Women can move between different jurisdictions and professionals during their pregnancy; taking their records with them ensuring the history taking process is not repeated with each new health professional. This promotes improved communication and improved risk management in maternity care provision. iProc order number 100319K. The WACHS NWHPR antenatal sticker can be ordered separately via iProc UCN 186367R (one roll has 250 stickers).
MR8C WACHS Outpatient Maternal Postnatal Assessment
Outpatient Maternal Postnatal Assessment form. iProc Order Number 189006Y
MR8D WACHS Outpatient Newborn Postnatal Assessment
Outpatient Newborn Postnatal Assessment form. iProc Order Number 189007A
MR8E WACHS Postnatal Clinical Phone Advice Form
MR8E WACHS Postnatal Clinical Phone Advice Form. iProc Order Number 189008B
MR90.1 WACHS Caesarean Section Operation Report
MR90.1 WACHS Caesarean Section Operation Report
MRK7110 BMHU Boarders Information and Agreement Form
Information and Agreement Form for boarders at the unit.
MRK7124 BMHU Patient Injury Debriefing
MRK7124 Patient Injury Debriefing - Broome MentalHealth Unit
MRO Screening and Patient Placement - Screening Requirements Flowchart - Wheatbelt
This flowchart sets out the required process of MRO screening and placement of patients in the Wheatbelt.
Multiple Chemical Sensitivity and Chemical Hypersensitivity Guideline
The WA Country Health Service (WACHS) Multiple Chemical Sensitivity / Chemical Hypersensitivity Guideline has been provided to minimise the effects of common hospital and health care incitants on people who identify as having MCS and require treatment in a hospital setting or need to visit a person close to them, who is in the hospital.
My Health Record Manual
This manual applies to all WACHS staff who have been authorised to access the MHR system, clinicians that provide document content to upload to the MHR, system administrators and training/support staff that facilitate the Consent Management Protocol for MHR and those that interact or oversee staff that interact with patients that may have a MHR. This manual also applies to any contracted service provider of WACHS who has been authorised to access the MHR system or the HI Service on behalf of the WA health system and/or WACHS.

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Negative Pressure Isolation Room Procedure - Busselton Health Campus
Control of environmental factors is necessary to limit airborne transmission of microorganisms such as measles, chicken pox and mycobacterium tuberculosis (TB).
Negative Pressure Isolation Rooms Type 5 Procedure - Albany Hospital
Control of environmental factors is necessary to limit airborne transmission of micro-organisms such as measles, chicken pox and Mycobacterium tuberculosis (TB).
Neonatal Admission Discharge and Transfer Procedure - Bunbury Hospital
Wherever possible, neonates requiring specialist intensive care are to be transferred in utero and born at a tertiary health facility that is able to provide the appropriate level of care. National accreditation of a Level 2A (WA Clinical Service Framework Level 4) neonatal facility at Bunbury hospital requires service definition and an agreed admission criteria.
Neonatal and Paediatric Continuous Positive Airway Pressure (CPAP) Guideline
While the WACHS endorses the Queensland Department of Health Maternity and Neonatal Clinical guideline for Neonatal Respiratory Distress including CPAP for both neonatal and paediatric Bubble CPAP therapy, this guideline sets out the WACHS specific information that differs to the QLD guideline.
Neonatal Resuscitation - Who Attends Low Moderate and High Risk Births Procedure - Broome Hospital
Broome Hospital provides elective low and moderate risk obstetric services, and emergency (unplanned) high risk deliveries for maternal or fetal compromise. Efforts to relocate or evacuate high risk women and their in-utero infant(s) to tertiary care is to occur whenever practicable.
Neonatal Resuscitation Policy
This policy sets out the required clinical rosters to support resuscitation and care of newborns in maternity units for WACHS regional health service units.
Nephrostomy Tube Management Clinical Practice Standard
This CPS has been endorsed for use by WACHS and should be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.
Newborn Bloodspot Screening Specimen Collection by Non-Midwives Policy - Wheatbelt and Great Southern
This policy relates to the Newborn Bloodspot Screening test and how it can be undertaken by suitably trained health professionals in the Great Southern and Wheatbelt regions during inpatient admission at the hospital of birth, or after discharge - at either a hospital site, community health site or during a home visit.
No Photography or Filming Poster
No Photography or Filming poster
Nocturnal Enuresis Program Guideline
This document details the WACHS Nocturnal Enuresis Program which assists children (aged 5 to 17 years) and their families with nocturnal bedwetting.
Non-Hospital - Non-Remote Clinic Emergency Management Procedure
This document outlines the procedures to be followed for a Code Red, Black, Blue, Brown, Purple or Yellow for all Kimberley non-hospital / non-remote clinic sites.
Not for Cardiopulmonary Resuscitation Policy
This policy outlines how WACHS is to comply with State legislation which provides instruments (Advance Health Directive or Enduring Power of Guardianship) for people to plan in advance for circumstances when they are unable to make decisions for themselves.
Nurse Compounding of Antibiotics in Elastomeric Devices Guideline
This document provides guidance for the safe and appropriate preparation, handling and administration of intravenous antibiotics, prepared by registered nursing and midwifery staff, as a continuous intravenous infusion for patients utilising the services of the Hospital Nurse Discharge Service or equivalent.
Nurse Escort - Patient Transfer Procedure - Broome Hospital
This document is designed to guide staff in the decision making process of utilising a nurse escort when transferring patients between units / areas.
Nurse Escort - Patient Transfer Procedure - Roebourne Hospital
This document is designed to guide staff in the decision-making process of utilising a nurse escort when transferring patients between units / areas.
Nurse Escort Procedure - Onslow Hospital
This document is designed to guide staff in the decision-making process of utilising a nurse escort when transferring patients between units/areas.
Nurse Escort Transfer Procedure - Geraldton Hospital
This procedure is designed to guide the decision making process when considering the movement of a patient between areas with a nurse escort, and is to be read in conjunction with the WACHS Interhospital Patient Transfer Policy.
Nurse Practitioner Guidelines for Emergency Care and Remote Area Healthcare Sites
The WA Country Health Service approves nurse practitioner clinical practice guidelines to assist nurse practitioners to make appropriate decisions about the specific clinical needs of patients. These guidelines reflect the legislation that regulates the practice of nurse practitioners (NP). This policy outlines the endorsed resources for use by nurse practitioners credentialed and working as a nurse practitioner at remote area health care centres and/or emergency care sites.
Nursing and Allied Health Student Clinical Placement Policy
This policy relates to all students from the nursing, midwifery and allied health disciplines, enrolled in a training program with an accredited Australian Tertiary Institution, Vocational Education and Training Provider, Registered Training Organisation or accredited re registration / refresher program provider.
Nursing and Midwifery Council Terms of Reference
The Nursing and Midwifery Council (NMC) primary role is to provide strategic, clinical and management leadership to the WACHS Executive on WACHS nursing and midwifery issues with the objective of continuously improving clinical outcomes and patient safety.
Nursing Management of the Neutropenic ADULT Haematology and Oncology Patient Procedure
This procedure sets out the immediate nursing management requirements of neutropenic patients
Nursing Roster Procedure
This procedure has been developed to guide a consistent process across WACHS. There may be variances of circumstance in individual regions however adherence to these principles is an expectation. It is acknowledged that rosters are a key component in staff satisfaction and retention. The accommodation of staff requests will be considered where practicable, distributed equitably however the priority of a roster is to meet service needs.
Nursing Shift to Shift Bedside Clinical Handover - Nursing Process Flowchart
Nursing Shift to Shift Bedside Clinical Handover - Nursing Process Flowchart
Nutrition Clinical Practice Standard
The purpose of this document is to establish minimum practice standards for the identification and management of malnutrition; and adequate nutritional status of patients throughout the WA Country Health Service (WACHS).
Nutrition Supplement and Enteral Feed Supply Scheme for Post Discharge and Outpatient Use Procedure
This procedure applies to all staff in the WACHS Great Southern (GS) involved in the provision of care of patients requiring enteral feeds or nutritional supplements to patients at home when unable to access via normal channels [Home Enteral Nutrition (HEN) program via nutrition supply companies].

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Obesity, Bariatric Surgery and Pregnancy - Consumer Fact Sheet
Consumer information about obesity, bariatric surgery and pregnancy.
Obst Pt Ref Admin and Transfer Criteria to a Higher or Tertiary Level Care Procedure for Birthing Sites - Kimberley
This procedure relates to women who can be delivered in Kimberley hospitals and has been developed with reference to Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and the King Edward Memorial Hospital (KEMH) guidelines.
Obstetric and Midwifery Level of Service Escalation and Referral Procedure - Busselton Hospital
The Busselton Health Campus (BHC) is committed to providing high quality, safe and effective obstetric and midwifery care at Clinical Service Framework (CSF) Level 3 as per the WACHS Maternity and Newborn Policy (2014) to women living in our community in accordance with the Department of Health Guidelines for Rural Obstetrics and Midwifery.
Obstetric and Midwifery Level of Service Procedure - Bridgetown Hospital
This site procedure applies to registered midwives and visiting medical practitioners holding appropriate clinical privileges in obstetrics and caesarean capability for the Bridgetown Hospital.
Obstetric Non-Standard Management Plan Guideline
In clinical practice, the care and safety of the woman and her unborn baby is our primary concern. Best practice requires all health professionals to: - provide all information required to assist women make well informed decisions - assess the woman, as an individual, including: - history - relevant obstetric risks, psychosocial and cultural aspects - physical assessment - with appropriate consent - woman's views and wishes. - refer the woman to another practitioner if appropriate - recognise and respect women's rights to make their own decisions - provide clear and unbiased communication without coercion or the use of fear. To order these low volume usage stickers you need to place a NON-catalogue iPROC order as below: Description - WACHS Non-Standard Management Plan Sticker Supplier code - HCWZZLAB0002. Unit of issue - 1 box (roll of 50) Supplier - Print Media Cost - $40.54
Occupational Biohazard Exposure Management Procedure - Midwest
This document is to be read in conjunction with the WA Health Management of Occupational Exposure to Blood and Body Fluids in the Health Care Setting Policy. WA Country Health Service (WACHS) Midwest, policies and procedures exist for the management of the Health Care Workers (HCW) who are occupationally exposed to blood or body fluids.
Occupational Exposure to Blood and Body Fluid Procedure - Great Southern
To prevent occupational injury with blood or body fluids and to monitor and manage risks to Great Southern staff related to occupational exposure.
Occupational Exposure to Blood and Body Fluid Procedure - South West
The purpose of this document is to provide Health Care Workers (HCW) with guidelines for the management of an exposure to another person's blood or body fluids in healthcare settings.
Occupational Exposure to Blood and Body Fluids Procedure - Wheatbelt
The purpose of this document is to provide Health Care Workers (HCW) with guidelines for the management of an exposure to another person's blood or body fluids in health care settings.
Occupational Safety and Health Policy
This policy is supported by an Occupational Safety and Health Management Framework which is aligned to the elements of the Worksafe Plan and outlines the governance model for the effective management of occupational safety and health across WACHS It is also supported by a number of additional policies, procedures and guidelines that provide practical guidance regarding the management of occupational safety and health within WACHS.
Offshore Aeromedical Retrievals Policy
WACHS staff members are prohibited from deploying on offshore aeromedical retrievals. Any requests for WACHS staff to deploy to offshore locations are to be escalated to the respective Regional Director and/or Regional Executive On Call who will advise the requesting agency of potential alternative options, including referral to the Royal Flying Doctor Service or private aeromedical providers.
Ombudsman Request for Information (Child Death Review) Procedure
This document outlines the process by which a Ombudsman request for information regarding a Child Death Review is communicated from the WA Country Health Service to the Ombudsman Western Australia, key positions responsible for responding to and developing a submission for the Ombudsman and format for information to be provided to the Office of the Director General.
Open Disclosure Procedure
The WA Country Health Service (WACHS) complies with the WA Health Open Disclosure Policy Statement February 2015 and practises open disclosure in accordance with the Australian Open Disclosure Framework and the National Safety and Quality Health Service Standards - Standard 1 Governance requirements.
Operation of Needle and Syringe Programs Procedure - Pilbara
This procedure outlines the operation of Needle and Syringe Programs (NSP) provided by the WA Country Health Service in the Pilbara region.
Operative Vaginal Delivery Procedure
This procedure for has been developed as part of an action plan to address obstetric sentinel events that have occurred at WA Country Health Service (WACHS) maternity sites and to reduce the likelihood of unsuccessful operative vaginal delivery.
Ordering S8 and S4R Medications from S100 Supply Procedure - Fitzroy Valley
The aim of this procedure is to reduce the risk of loss or theft of restricted medication while in transit to or from the Remote Area Clinics (RAC).
Ordering, Storage and Recording of Restricted Schedule 4 Medicines Policy
Subsequent to direction from OD 0215/09 Schedule 4 Recordable Medications, this policy ensures an acceptable level of control for these medications within WA Country Health Service (WACHS) facilities.
Outbreak Management Action Plan - Gastroenteritis Procedure
This procedure describes the organisation's preparedness and response in the event of a potential or actual gastroenteritis outbreak, and includes the appropriate patient safety and quality of care practices to prevent the spread of infection while maintaining organisational activity.
Oxygen Therapy and Respiratory Devices - Adults Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management in adults for oxygen therapy and respiratory devices throughout the WA Country Health Service (WACHS). For paediatric patients, refer to Princess Margaret Hospital (PMH) Clinical Practice Manual: - Oxygen Administration Procedure - Oxygen Delivery Devices - Oxygen and Suction Equipment Maintenance - Humidified High Flow Nasal Cannula Therapy for Children - Humidified High Flow Therapy Equipment Set-Up For neonates, refer to the King Edward Memorial Hospital (KEMH) Neonatal Directorate Clinical Guidelines (refer to section 2 - Respiratory Problems and Management)

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Paediatric Medical Staff Attendance for At Risk Births Procedure - Kalgoorlie Hospital
This procedure clarifies when paediatric attendance is required at a birth.
Paediatric Team Attendance for 'At Risk' Births Procedure - Bunbury Hospital
This procedure sets out the responsiblities of the obstetric and/or midwifery staff around who is to be called in, and under which circumstances, to attend an 'at risk' birth.
Parking Arrangements at WACHS Central Office Procedure
This procedure sets out the parking entitlements for employees of, and visitors to, WA Country Health Service (WACHS) Central Office metropolitan sites.
Partnering with Consumers Guideline
This guideline supports the WACHS Consumer and Carer Engagement Policy by outlining the engagement and governance processes to be used by all WACHS staff to strengthen and improve the ways that we listen to and work with consumers and carers across our health services.
Patient Administration System and Clinical Systems Business Rules Policy 1.00
These business rules have been established to support good practice and data compliance across the clinical systems and provide a single source of information to guide system usage and data entry.
Patient Admission Procedure - Broome Mental Health Unit
This procedure sets out the admission process for patients to the Broome Mental Health Unit
Patient and Property Searches Procedure - Albany Hospital Acute Psychiatric Unit
This procedure sets out how the APU will take all reasonable steps to ensure that admitted patients, detained persons and persons presenting to the mental health service do not present a risk of harm to themselves or others by having inappropriate items in their possession and/or bringing then into mental health inpatient unit.
Patient Assisted Travel Scheme - Exceptional Ruling Guideline
This document covers Exceptional rulings that are made when an applicant meets the intent of the PATS scheme, which is equitable access to specialist medical services for people living in country Western Australia, but does not clearly meet the strict parameters of the PATS policy.
Patient Assisted Travel Scheme Policy
The Patient Assisted Travel Scheme (PATS) is funded by the WA State Government through the Royalties for Regions (RfR) scheme and is administered by the WA Country Health Service (WACHS) Country Health Innovation (CHI) program. The intent of the Patient Assisted Travel Scheme (PATS) is to address variability in health outcomes, service access and equity for country people by providing financial assistance to eligible country residents to access eligible medical services not available locally.
Patient Bed Flow Procedure - Broome Mental Health Unit
The purpose of this procedure is to provide guidance for consistent patient flow processes and equitable bed management practices across the Kimberley and Pilbara regions.
Patient Discharge Procedure - Broome Mental Health Inpatient Unit
This procedure sets out the requirements for, and process of discharging of patients from the Broome Mental Health Inpatient Unit.
Patient Identification Policy
The National Safety and Quality Health Service (NSQHS) Communicating for Safety Standard requires organisations to have correct ID and procedure matching systems in place to maintain the identity of the patient and to ensure that the patient receives the care intended for them. Whilst the term 'patient' is used in the title of this policy, it may be at times used interchangeably with clients or residents, depending on the context of the health setting.
Patient Injury Procedure - Broome Mental Health Unit
This procedure sets out how to ensure that patients are given appropriate medical attention if injured during an accident or incident while an inpatient.
Patient Leave Procedure - Albany Hospital Acute Psychiatric Unit
This procedure sets out how leave is granted to voluntary and involuntary patients of the Albany Hospital Acure Psychiatric Unit.
Patient Leave Procedure - Broome Mental Health Inpatient Unit
This procedure sets out the process to be followed for Involuntary and Voluntary patient leave from inpatient mental health unit.
Patient Observation Procedure - Broome Mental Health Unit
This procedure provides information in relation to mental health risk assessment and observation categories for patients admitted to the Broome Mental Health Unit (Mabu Liyan).
Patient Opinion Response Procedure
This procedure outlines the approach to assessing, responding to, and recording Patient Opinion (PO) stories received by subscribed WA Country Health Service (WACHS) regions.
Patient Property and Valuables Procedure - Busselton Health Campus
The purpose of this procedure is to ensure safe management of patients' property and valuables within the Busselton Health Campus.
Patient Property and Valuables Procedure - Midwest
The purpose of this procedure is to ensure safe management of patients' property and valuables within the Midwest region.
Patient Property Procedure - Broome Mental Health Unit
This document sets out the procedure for the responsibility and storage of patient property as required.
Patient Rights and Responsibilities Procedure - Broome Mental Health Unit
This document sets out how the Broome Mental Health Unit (BMHU) / Mabu Liyan upholds the rights of patients to ensure they are treated with respect and dignity in accordance with the Charter of Mental Health Care Principles.
Patient Safety Directive and Patient Safety Update Process Policy
The Patient Safety Directive Process System is a WA Country Health Service area wide risk management and communication strategy, which provides direction and information to regional operational areas commensurate with the extent and evidence of the clinical risk identified.
Patient Support Service Patient Companion Shift Procedure
Patient Support Assistants (PSAs) are not to be required to provide unsupervised patient management. At all times, the PSA is to work under the direction of nursing staff.
Patient Transport Assistance Procedure - Busselton Health Campus
This procedure outlines how eligible patients may be assisted with transport via public transport, community based transport, taxis, or patient transport ambulances.
Patient Transport Escalation Flowchart - Wheatbelt
This flowchart sets out the process for the transport of Wheatbelt patients after the initial decisions to transfer have been made.
Patient Trust Monies Policy
This policy is prescribed to ensure that the patient trust monies received by the WA Country Health Service are recorded and disbursed correctly in accordance with the patient's wishes and procedures and policies set out henceforth.
Patient Vehicle Access Procedure - Albany Hospital Acute Psychiatric Unit
This procedure outlines how to support the right of patients to be treated in a way that balances the need to impose the least restriction on patient rights and freedoms, with the need to protect patient safety and that of others in the community.
Patient Visitors Procedure - Broome Mental Health Unit
This document aims to provide a safe and enjoyable environment for staff and visitors during visiting times.
Patient Voting Procedure - Albany Hospital Acute Psychiatric Unit
This procedure provides guidance on determining whether an involuntary mental health patient has the capacity to vote.
Patients' Valuables Procedure - Kalgoorlie Health Campus
This document sets out the procedure to be followed with regard to patients' property and valuables.
Peer Review Position Statement
Peer Review is a critical element in any organisational clinical quality system and this statement provides information to support clinicians when conducting peer reviews to assure, maintain or enhance quality of work / performance and improve patient safety and health outcomes. This aim of this document is to assist staff, services and programs to recognise the minimum standards for peer review processes within WACHS.
Periodic Reporting on Payment of Invoice Against Credit Term Procedure
Treasurer's Instruction (TI) 323 requires commercial invoices to be paid within 30 days from the date of claim, unless the underlying contract specifies otherwise, or a discount is available. This procedure sets out how all regions are to undertake this process.
Peripheral Intravenous Cannulae (PIVC) Management Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the insertion, care and management of peripheral intravenous cannulae (PIVC) throughout the WA Country Health Service (WACHS).
Peripheral Vasopressor Infusion Guideline - Adults
The goal of this guideline is to establish a safe practice for the use of peripheral vasopressor agents in WA Country Health Service sites.
Peripherally Inserted Central Catheter (PICC) Line Consumer Information Sheet
This information sheet will support the care of PICC Line in the home to reduce infection risks.
Personal Protective Equipment (PPE) Procedure
This procedure is to inform all staff, students, volunteers, researchers, contractors and visitors that work or visit WACHS sites of the Personal Protective Equipment (PPE) requirements they need to adhere to when entering WACHS sites or performing their duties. This document supports the Environmental Cleaning Policy, Infection Prevention and Control Policy and Managing Hazardous Chemicals Procedure.
Pharmaceutical Representative Management Across the South West Procedure
This procedure outlines the appropriate process to follow for interaction with pharmaceutical representatives. It considers both the access to the facilities and staff as well as the process required around potential acceptance of pharmaceutical samples.
Photography and Filming - Consumer Information Sheet
Photography and Filming Information Sheet for consumers.
Photography and Filming of Clinical Care by Patients, Carers, Relatives, Visitors or Contractors Policy
This policy governs the requirement that patients, carers, relatives, contractors or visitors do not use cameras, mobile phone cameras, video cameras or other image capture devices on WA Country Health Service premises without prior approval and consent of all persons identifiable in the images.
Physiotherapy - Safe Use of Western Acupuncture and Dry Needling Policy
This policy sets out the requirements for physiotherapists utilising techniques involving skin penetration for the treatment of pain and other symptoms of musculoskeletal disorders, or as a measure to improve functional health status within the current scope of physiotherapy practice.
Pin Site Care Clinical Practice Standard
This CPS has been endorsed for use by WACHS and should be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.
Pneumatic Tube Procedure - Busselton Health Campus
This document sets out the procedure for use of the Pneumatic Tube Conveyor System which is used to convey specified items in the safest, most efficient and most effective way possible between departments.
Police Attendance Procedure - Broome Mental Health Inpatient Unit
This document outlines the procedure to be undertaken in the event of police attendance at the unit.
Police Involvement in the Assessment, Management and Transfer of Aggressive Patients Flowchart
This flowchart sets out the process for the assessment, management and transfer of aggressive patients (in the South West).
Policy Development Flowchart
This flowchart is to be read in conjunction with the WA Country Health Service (WACHS) Policy Development Policy.
Policy Development Policy
This policy enables WACHS to standardise the approach toward the attainment of goals, values and objectives, to ensure the achievement of desired standards of health service delivery, to minimise risk and to meet legislative and governance requirements. All policy documents are to be progressed through the structures and processes outlined in this policy and the supporting Policy Development Flowchart.
Post-Operative Nausea and Vomiting Guideline - Albany and Katanning Hospitals
The aim of this document is to provide staff with a structured approach in the management of post-operative nausea and vomiting (PONV)
Power to Detain a Child Under the Age of Six in Hospital Procedure
Hospitals have legislated power under Part 4, Division 2, Subdivision 4, Section 40 of the Children and Community Services Act WA 2004 (the Act), to detain a child, under the age of six (6) years, in hospital where there is a reasonable belief that the child is at imminent risk of harm. This documents sets out the processes that are to be undertaken in such circumstances.
Pre and Post Procedural Management Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management immediately prior to, and following a procedure throughout the WA Country Health Service (WACHS) and is to be used in conjunction with WACHS Theatres Clinical Practice Standard. Further information relating to specialty areas including Child and Adolescent Health Service (CAHS), Women and Newborn Health Services (WHNS) can be found via HealthPoint if not covered in this policy.
Pre-Anaesthetic Fasting - Paediatric Patients Procedure
This procedure aims to ensure the safest outcome for patients who require general anaesthesia or sedation for surgery and/or interventional procedures.
Pre-Employment Health Assessment Policy
Health screening is provided to new and existing employees to ensure they can safely perform the duties for which they are to be employed, and to allow managers to incorporate reasonable working guidelines if it is medically indicated that a pre-existing injury or health condition may be affected by those duties.
Pre-Employment Health Assessment Procedure - Great Southern
This procedure is to be read in conjunction with the WACHS Pre-employment / Pre-placement Medical Health Screening Policy and the WA Health Health Care Worker Immunisation Policy and is relevant to all appointments, including existing employees who are applying for a new position.
Pre-Employment Health Assessment Process Flowchart - Wheatbelt
This procedure operationalises the WACHS Pre-Employment Heath Assessment Policy in the Wheatbelt.
Pre-Employment Pathology Ordering Procedure - Pilbara
The N10 Pre-Employment Health Assessment is used to advise management of an employee's immunisation status and any pre-existing health issues. Infection Control Clinical Nurses reviewing N10 Part B for vaccine preventable disease (VPD) status, methicillin-resistant Staphylococcus aureus (MRSA) status, or baseline assessment of tuberculosis status can complete and sign pathology request forms for routine screening as required by pre-employment assessment. Nurse Managers in Tom Price, Paraburdoo, Newman, Onslow, and Roebourne can complete and sign pathology request forms for routine screening as required by N10 or as recommended by Infection Control Clinical Nurses.
Preoperative Staphylococcus Aureus Screening for High Risk Surgery Procedure - Midwest
WACHS Midwest strive to prevent hospital acquired surgical site infections (HA-SSI) and recommends screening of patients for carriage and/or colonisation with Staphylococcal Aureus (SA) prior to surgery. SA refers to both methicillin-susceptible SA [MSSA] and methicillin-resistant SA [MRSA]. SA is a pathogenic organism that can cause significant infection when it enters the body through broken skin and causes a wide range of clinical disease. Significant morbidity and mortality risks are associated with postoperative SA infection. Preoperative screening of patients is indicated to identify SA carriers to enable targeted decolonisation, and the appropriate choice of prophylaxis in an effort to prevent post-operative SSI's
Prescribing and Accessing Clozapine for Patients Admitted to Bunbury Hospital Outside of Pharmacy Hours Procedure
This procedure outlines the process by which to access clozapine for patients admitted to the Bunbury Hospital after hours.
Prescription and Supply of Slide-In (Not Fixed) Bed Rails Bed Poles for Admitted and Non-Admitted Patients Guideline
This guideline applies to use of slide-in bed rails/bed poles which are prescribed for the purpose of improving bed mobility and assisting in transfers into and out of the bed. It does not include fixed or integral devices that are designed to prevent the user from rolling out of the bed (See Section 4 Definitions). Hospital beds have integral side rails and profiling mattresses as a standard so the use of slide-in devices is generally not appropriate in these settings and may be contraindicated.
Presentation of Information at a Conference Procedure
This document sets out the required approval process for staff wishing to present information at conference.
Pressure Injury Prevention and Management Policy
This policy addresses the requirements for the prevention and management of pressure injuries for adult, maternity, newborn and paediatric inpatients and aged care residents within WA Country Health Service (WACHS) healthcare facilities.
Prevention of Maternal and Newborn Sepsis Policy
WACHS will now adopt the risk-based approach to prevention of EOGBSD and sepsis in the maternal and newborn setting rather than the current KEMH approach of universal GBS screening and risk based management
Prevention of Workplace Aggression Procedure - Goldfields Mental Health Service
This procedure outlines how GMHS staff are to deal with incidents of aggression, intimidation, threatening or violent behaviour.
Primary Postpartum Haemorrhage Guideline
The aim of this guidleline is to minimise the risk of harm to women from primary post partum haemorrhage (PPPH) in WA Country Health Service (WACHS) health care services.
Princess Margaret Hospital (PMH) Guidelines - EUCP Policy
WACHS has endorsed Princess Margaret Hospital (PMH) guidelines for use in clinical practice.
Procedural Sedation - Emergency Department Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for procedural sedation throughout WA Country Health Service (WACHS) emergency departments
Procurement Handling and Recording of Nitrous Oxide and Medical Gases containing Nitrous Oxide Procedure
This procedure relates specifically to consideration around the procurement and storage of both nitrous oxide and Entonox gas cylinders at a hospital and ward level within WACHS - South West facilities.
Professional Development Requirements for Midwives Policy
The WA Country Health Service (WACHS) is committed to developing and fostering a culture of learning which encourages self-development and the assessment of clinical skills and knowledge to ensure the safe and competent provision of maternity care.
Prohibited Items Procedure - Albany Hospital Acute Psychiatric Unit
This procedure sets out how the APU is to take all reasonable steps to ensure that admitted patients, detained persons and persons presenting at a mental health service do not present a risk of harm to themselves or others by having inappropriate items in their possession and/or bringing then into the APU.
Project Management Policy
The WA Country Health Service (WACHS) undertakes a number of time limited projects that deliver an organisational change. Projects have a defined scope, deliverables, start and end dates, cost and can be conducted in an appropriate quality controlled manner.
Project Support Office Governance Working Party - Terms of Reference
The PSOGG is the principal governance body for the WA Country Health Service (WACHS) Project Support Office providing advice and oversight in relation to the monitoring of key projects. The PSOGG acts as an assurance mechanism to the CE/Board to help ensure that WACHS projects are delivered appropriately.
Provision of Domiciliary Oxygen for Travel in WA Guideline
This guideline is to ensure the flexible supply of domiciliary oxygen to Western Australians who meet the clinical indications for therapeutic benefit from the provision of domiciliary oxygen.
Public Health Management of Acute Post-Streptococcal Glomerulonephritis Guideline
Acute post-streptococcal glomerulonephritis (APSGN) is an immune mediated condition, characterized by glomerular inflammation precipitating kidney dysfunction occurring 7-10 days following streptococcal pharyngitis or 2-4 weeks following streptococcal skin infection. While Group A Streptococcus (GAS) infection is the most common cause, Group C streptococci have also been associated with glomerulonephritis.
Public Health Management of Mumps Outbreaks Guideline
This document provides guidance for regional Public Health Teams to support the management of mumps outbreaks in regional Western Australia.
Public Health Workforce Surge Guideline
During a public health incident/outbreak it is important that the public health workforce has adequate capacity to an effective response. This requires a sufficient number of available staff with the necessary skills and expertise to meet rising demands. This document provides guidance for the surging of staff in WACHS in response to communicable disease outbreak or health protection events that exceed existing capacity.
Publications for Consumers Procedure - Kimberley
The purpose of this procedure is to provide staff with clear instructions on the process for the development, approval and publication of consumer / client information.
Purchasing Card Audit Procedure
In line with the WA Country Health Service (WACHS) Purchasing Card (P Card) Guidelines, and to improve the governance and controls associated with the use of Purchasing Cards; WACHS Central Office Finance has implemented a periodic centrally controlled P Card audit check procedure.
Purchasing Card Guideline
This guideilne outlines Purchasing Card use by WACHS employees.
Purchasing Card Spot Check - Checklist Tool
This checklist is to be used for auditing a random sample of WACHS P Card holders in line with the WACHS Purchasing Card Audit Procedure.

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Radiation Skin Care Clinical Practice Standard
This CPS has been endorsed for use by WACHS and should be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.
Radiology - Imaging Pregnant Patients Procedure
The aim of this document is to provide all medical imaging staff employed by the WA Country Health Service (WACHS) with a consistent procedure when conducting a diagnostic imaging radiology procedure on a patient who is pregnant or possibly pregnant.
RC10 WACHS Pain Intervention and Evaluation Record
WACHS Residential Aged Care Form
RC12 WACHS Bowel Management Record
WACHS Residential Aged Care Form
RC13 WACHS Behaviour Assessment
WACHS Residential Aged Care Form
RC15 WACHS Dietary Preference
WACHS Residential Aged Care Dietary Preference form
RC17 WACHS Continence Assessment form and Care Plan
WACHS Residential Aged Care Form
RC18 WACHS Three Day Bladder Chart
WACHS Residential Aged Care Form
RC2 WACHS Initial Enquiry for Accommodation
WACHS Residential Aged Care Form
RC21 WACHS Sleep Assessment
WACHS Residential Aged Care Form
RC22 WACHS Personal and Social History
WACHS Residential Aged Care Form
RC23 WACHS Activities Assessment
WACHS Residential Aged Care Form
RC24 WACHS Monthly Activities Planner
WACHS Residential Aged Care Form
RC25 WACHS Case Conference Checklist
WACHS Residential Aged Care Form
RC26 WACHS Ability to Self Medicate
WACHS Residential Aged Care Form
RC29 WACHS High Risk Behaviour Consent
WACHS Residential Aged Care Form
RC35C WACHS Personal Contacts Form
WACHS Residential Aged Care Form
RC36 WACHS Blood Glucose Monitoring
WACHS Residential Aged Care Form
RC4 WACHS Resident Orientation
WACHS Residential Aged Care Form
RC43 WACHS Restraint Assessment
WACHS Residential Aged Care Form
RC44 WACHS Restraint Chart
WACHS Residential Aged Care Form
RC5 WACHS Resident Admission Assessment
WACHS Resident Admission Assessment
RC6 WACHS Specific Care Plan
WACHS Residential Aged Care Form
RC7 WACHS Resident Care Plan
WACHS Resident Care Plan
RC9 WACHS Pain Assessment
WACHS Residential Aged Care Form
Receipt, Storage and Collection of General Practitioner Vaccines - Busselton Health Campus
Under the current contract, Busselton Health Campus (BHC) is a delivery point for vaccines that are supplied to General Practitioner (GP) surgeries under the 'free vaccine program'. Under this program, vaccines are ordered directly by the GP surgery and are delivered pre-packaged to BHC. The vaccines are then collected by a GP surgery representative.
Recognising the Importance of Carers Policy
All WACHS employees and contractors are to involve carers, and/or persons or bodies that represent carers, in any policy or program development, or strategic or operational planning, that might affect carers and the role of carers. Consumers (and their families and/or carers) are to be engaged as partners in their own health care, support, treatment, care planning and self-management.
Recognition and Response to Acute Deterioration (RRAD) of the Newborn Policy
The purpose of this policy is to ensure that newborns known to be at increased risk of clinical deterioration following birth are recognised and receive timely, appropriate clinical management to minimise their risks. It also provides guidance on cord blood gas collection, analysis and interpretation, and on the optimal timing of cord clamping following birth.
Recognition and Response to Clinical Deterioration at Remote Area Clinics Procedure
This procedure oultines the process for for clinical escalation to achieve evacuation of the unwell patient from the One Arm Point, Lombadina, Looma, Noonkanbah, Bayulu, Wangkatjungka, Warmun and Kalumburu Clinics.
Recommendations for Acute Pain Management in Adults - Systemic - Albany Hospital
This guideline sets out recommendations for the systemic management of acute pain management in adults.
Records Management Policy
This policy sets out how, in accordance with Section 17 of the State Records Act 2000), the WA Country Health Service (WACHS) and its employees are to identify, capture, manage, control, preserve and dispose of government records.
Referral and Transfer of Patients between ED and Community Mental Health Procedure
Hospital Emergency Departments (ED) and Community Mental Health (CMH) clinical staff have clear direction in the processes for the referral and transfer of patients between services
Referral to Regional Cancer Centres Medical Oncology Services Procedure
WACHS Regional Cancer Centres are aligned with the state cancer plan and are part of a state wide network with links to Tertiary Cancer Centres. This document sets out the WACHS wide referral system for public patients visiting medical oncology services ensuring the right patient is assessed by the right clinician, at the right time, in the right place, with the right resources.
Regional Drug Formulary Procedure - South West
This procedure outlines the processes that will be utilised to maintain the WACHS - South West Regional Drug Formulary. The WACHS-SW Regional Drug Formulary is, as of the October 2017, a combination of the WA Statewide Medicines Formulary (SMF) and other approved medicine supply arrangements determined by the WACHS-SW Drugs and Therapeutics Committee (DTC) as listed in this procedure.
Regional Product Evaluation and Standardisation (PESC) Committee - Terms of Reference
The group is known as the Regional Product Evaluation and Standardisation Committee (PESC) with the region added as a suffix e.g. PESC Goldfields. The purpose of the Regional Product Evaluation and Standardisation Committee is to ensure that medical equipment and consumables (excluding pharmaceuticals and radiological items) are managed safety and used efficiently and effectively as required for compliance with Corporate EQuIP National Standard 15.15.1 and 15.16.1.
Registered Nurse, Midwife and Mental Health Nurses - Postgraduate Qualification Allowance Approval Flowchart
This flowchart outlines the process for approval of Post-Graduation Qualification Allowance.
Renal - Hepatitis B Vaccination - Patients with Advanced Chronic Kidney Disease Clinical Practice Standard
This CPS has been endorsed for use by WACHS and should be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.
Renal - Parathyroidectomy - Patients with Advanced Chronic Kidney Disease Clinical Practice Standard
This CPS has been endorsed for use by WACHS and should be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.
Request for a Patient to have a Boarder Form - Great Southern
Great Southern Form to request for a patient to have a boarder.
Request for Supply of Non-PBS Pharmaceutical or Medical Supplies Form
The provision of Non-PBS Pharmaceuticals or Medical Supplies from a public hospital is not an automatic entitlement for any patient. This application form is completed for consideration by the Regional Medical Director for supply of non-PBS pharmaceuticals or medical supplies.
Requesting Additional Security Personnel Procedure Flowchart - Bunbury Hospital
When the need for additional security staff is identified, this flowchart sets out how it is to be escalated and actioned.
Requisitioning and Receipt of Schedule S4R and 8 Medications and Ordering of Pharmacy Imprest Supplies Procedure
This procedure demonstrates the correct process for the ordering and receipt of Pharmacy Imprest supplies, Schedule Four Recordable (S4R), Schedule Eight (S8) medications in the WA Country Health Service (WACHS) to ensure safe and accountable practice.
Residential Aged Care - Admission to a Residential Facility Flowchart
WACHS Residential Aged Care Flowchart
Residential Aged Care - Allied Health Services Flowchart
Referral process for aged care residents to WACHS allied health services.
Residential Aged Care - Audit Procedure
The purpose of this document is to ensure a standardised approach to audits in WACHS Residential Aged Care facilities, to improve consumer outcomes by improving professional practice and general quality of all services delivered (both clinical and non-clinical).
Residential Aged Care - Pre-Admission Checklist Flowchart
WACHS Residential Aged Care Flowchart
Residential Aged Care - Process for Respite Admission for Aged Care Clients
WACHS Residential Aged Care Flowchart
Residential Aged Care Health Record Procedure
This procedure provides guidance and structure to the storage, management, documentation and filing of residential aged care records within the WA Country Health Service.
Residential Aged Care Services Policy
The purpose of this policy is to ensure that WA Country Health Service (WACHS) Residential Aged Care Facilities meet the National Safety and Quality Health Service Standards (NSQHS) and Aged Care Quality (ACQ) Standards and Standards of Clinical Practice outlined within WACHS policy documents. Commonwealth funded Residential Aged Care Facilities are to demonstrate compliance at all times with the ACQ Standards. Multi-Purpose Service Sites and Small Hospitals providing residential care are to demonstrate compliance with the NSQHS (including the Aged Care Module).
Responding to Non-Emergency Requests for Review of an Unwell Community Member Procedure
This procedure is designed to provide a process for gathering adequate information to make a timely and informed decision regarding escalation of the request to allow follow up assessment.
Responding to Sexual Assault Policy
This policy sets out the specific information for WACHS clinicians required to respond to SA presentations, and particularly information that may either differ from, or is not addressed, in the Women and Newborn Health Service SARC Procedure for responding to sexual assault (best practice).
Restraint Minimisation Policy
This policy outlines the requirements for all WACHS health services to act on eliminating, or minimising where possible, the use of restrictive practices, and meeting the requirements to practice safely and lawfully if restraint is applied during a period of health care.
Resuscitation, Education and Competency Assessment Policy
WACHS is committed to developing and fostering a culture of learning which encourages self-development and the assessment of clinical skills and knowledge in the resuscitation practices associated with newborns, infants, children and adults. This is centred on establishing learning and assessment programs to agreed standards and to ensure minimum safe practice. The agreed standard for resuscitation practices for WACHS is the Australian Resuscitation Council (ARC).
Reusable Medical Device Reprocessing Procedure - Great Southern and Midwest
Where Reusable Medical Devices are used and reprocessed, the health service must comply with current relevant legislation, national & international standards, and manufacturer's reprocessing instructions.
Review of Death Procedure
This procedure outlines WA Country Health Service minimum standards for review of deaths, tools agreed for use and reporting requirements.
Review of Death Process - Wheatbelt
This flowchart provides a guide for managers of the regional Review of Death process.
Review of Oracle Outstanding Purchase Order Reports Procedure
This procedure sets out the responsibilities for the regular review of Oracle and I-Pharmacy Open Purchase Order Reports.
RhD Immunoglobulin (Formerly Anti-D) Prophylaxis Procedure - Wheatbelt
This procedure outlines how the time critical administration of RhD immunoglobulin is to be managed in the Wheatbelt.
Risk Assessment for Admission of the Heavier Patient Policy
The purpose of the policy and procedure is to prevent and manage the manual handling risks existing within CHS by using a consistent, systematic Risk Management approach to identify, assess and control manual handling hazards in the workplace.
Risk Assessment for Admission of the Heavier Patient Site Assessment Form
This form is to be completed for the site on an annual basis (or sooner if there are significant changes to the workplace).
Risk Management Policy
WACHS considers risk management to be an important element of corporate governance and closely associated with the pursuit of improved business performance, innovation and productivity. The identification, analysis, acceptance, and mitigation of risk is essential to ensuring WACHS is providing services in a safe and effective manner to both patients and staff.
Role and Responsibility of Approved Radiographers and X-ray Operators Policy
This document clarifies the roles and responsibilities of approved radiographers/ medical imaging technologists (MITs) and x-ray operators (XROs) in the provision of the WACHS X-ray Operator Service.
Role of the Doula Consumer Brochure
This consumer brochure explains about the doula, who is a companion who understands the emotional and physical needs of a woman and her family throughout her pregnancy, labour, birth and early postnatal period, and provides continuous non-clinical support and non-clinical care for a woman throughout her whole experience.
Role of the Endorsed Privately Practicing Midwife for Private Patients at WACHS Maternity Sites Procedure
This purpose of this document is to provide guidance to WACHS maternity staff as to the EPPM scope of practice when credentialed to admit and provide care to their private patients within WACHS maternity services, and to confirm that the clinical governance and support for EPPMs are consistent with the health service's existing policies and processes an to provide definition around the roles and responsibilities of the collaborating parties, including responsibilities for care planning and provision, documentation and reporting of information.
Roles and Responsibilities for Infrastructure Projects Policy
This document attempts to outline the responsibilities and key activities of the key stakeholders that are involved in the project life cycle of a WA Country Health Service (WACHS) build asset.
Royal Flying Doctor Service (RFDS) Clinical Manuals - EUCP Policy
WACHS has endorsed the Royal Flying Doctor Service (RFDS) Clinical Manuals for use in clinical practice.
RPBG Nursing Practice Standard for Volumetric Pump Plum A+ - EUCP Policy
WACHS endorses the Royal Perth Bentley Group (RPBG) Nursing Practice Standard for Volumetric Pump Plumb A+ as evidence based recommended practice for use by Nursing and Midwifery staff.
Rural Gratuities Payment Process Flowchart
Flowchart to show Approval process for payment of Rural Gratuities.

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S4R and S8 Medications in DRKs, Parry Pack Retrieval Kits and Bunbury Hospital Retrieval Kits Procedure
Hospitals and nursing posts across the WACHS - South West region are required to maintain 'Parry Pack' Retrieval Kits and Disaster Response Kits (DRK) as per the relevant state Operational Directive and Information Circular. This procedure guides the handling and recording of S4R and S8 medications within these kits for the WACHS - South West region.
SAC 1 Clinical Incident - Multi-Agency Review Flowchart
This flowchart sets out the actions to be undertaken during the investigation of clinical incidents across health service boundaries.
Safe Driving Guideline
This guideline has been prepared to assist WACHS to meet its duty of care obligations and to assist employees to assess and control risks associated with the operation of fleet vehicles for work-related use.
Safe Driving Guideline Addendum A - Fleet Vehicle Business Case and Risk Assessment Workbook - Addendum
WACHS Fleet Vehicle Business Case and Risk Assessment Workbook.
Safe Driving Guideline Addendum B - Sample Fleet Vehicle Risk Assessment - Form
HCN Pre-Employment Health Assessment E-Form - CAN BE LOCATED VIA THE HCN WEBSITE.
Safe Driving Guideline Addendum C - Remote Area Chart - Addendum
Map defining the 'remote area' of Western Australia.
Safe Driving Policy
The WACHS recognises that the safety and health of its employees is of prime importance and acknowledges its obligations under the Occupational Health and Safety Act (1984).
Safe Driving Procedure
This procedure provides information on safe systems of work for employees driving a WACHS fleet vehicle outside of remote areas and should be read in conjunction with other relevant WA Health and WACHS policy documents.
Safe Driving Procedure - Goldfields
The Safe Driving Procedure Addendum G: Personal Safe Travel Plan Goldfields is to be used by all WACHS-Goldfields staff when undertaking travel by government vehicle in certain circumstances.
Safe Driving Procedure Addendum A - Long Journey Vehicle Inspection Sheet (Remote Area Use) - Checklist
This checklist is to be completed by the driver of a vehicle who will be undertaking a long journey in a remote area.
Safe Driving Procedure Addendum B - Personal Safe Travel Plan - Form
To be completed by the driver prior to undertaking a long journey with travel time of more than five hours continuous driving, for any journey where a journey risk assessment shows high safety risk or for any travel involving remote or isolated work.
Safe Driving Procedure Addendum C - Recovery Pack (Remote Area Use) Inspection - Checklist
A recovery pack is only required for use in remote areas subject to journey risk assessment. It is to be completed by the driver. A recovery pack is not to be used without specific training.
Safe Driving Procedure Addendum D - Journey Risk Assessment - Form
This document forms part of the Personal Safe Travel Plan and is to be submitted with the Personal Safe Travel Plan.
Safe Driving Procedure Addendum E - Survival Pack (Remote Area Use) Inspection - Checklist
The driver is to tick all items that are satisfactory. List items that are NOT satisfactory, report unsatisfactory items , and do NOT proceed on journey until all matters are satisfactory.
Safe Transport and Transfer of Care of Country Mental Health Patients Flowchart
Flowchart for the safe transport and transfer of care of country Mental Health patients
Safe Use of Medication Refrigerator Procedure
This procedure provides practical guidance for WACHS facilities to meet the requirements outlined in the The recently published Operational Directive OD 0587/15 WA Health Safe Use of Medication Refrigerators Policy
Safe Working Procedure for Interviewing Clients - Pilbara Mental Health and Drug Service
The Pilbara Mental Health and Drug Service (PMHDS) provides an assessment and treatment service to people within the Pilbara region who have a psychiatric disorder. This procedure relates to safety when interviewing clients at the interviewing rooms at the Port Hedland Health Campus (HHC) and the Nickol Bay, Newman and Tom Price hospitals.
Safety Risk Report Form
This is the form to be used for reporting safety risks.
Schedule 8 and Schedule 4 Restricted Medicine Discrepancies Notification Flowchart for Wards
This flowchart is a pathway to allow nomination of roles as required to facilitate involvement of appropriate staff in this process as per Operational Directive OD0377/12 .
Script Tracker - Medication Chart and Prescription Tracking Program Information Sheet - Bunbury Hospital
The information provided here is for guidance around the use of the software program, Script Tracker, which is a Pharmacy IT application that provides real time information on the progress of medication supply at the Bunbury Hospital.
Search and Seizure Procedure - Broome Mental Health Inpatient Unit
In the interest of patient, staff and visitor safety, there may be times when it is necessary to conduct a personal search of a patient, search a patient's belongings and /or a patient's room. This procedure outlines how this process is to take place.
Seclusion Procedure - Albany Acute Psychiatric Unit
For the purposes of this procedure, the term seclusion refers to seclusion in the patient's own bedroom which is considered an intervention used as a last resort.
Secure Access of Medication - Clean Utility Rooms via Medication Keys and Electronic Swipe Key Cards Procedure
This procedure relates to the safe working practices surrounding secure access of medication rooms including allocation of medication keys and swipe cards.
Secure Access of Medications via Medication Keys and Electronic Swipe Cards Procedure - Midwest
This procedure relates to safe working practices surrounding secure access of medication rooms including allocation of medication keys and swipe cards.
Security - Use of Handcuffs Procedure - Bunbury Hospital
This procedure has been developed to ensure staff and patients are protected from persons committing a breach of the WA Criminal Code where the perpetrator of the crime can be easily controlled with the application of handcuffs. Mechanical restraint, other than the use of a medical or surgical appliance for the proper treatment of a physical disease or injury (Section 230 Mental Health Act 2014) will not be operated in any guise for the control of health patients.
Security - Use of Oleoresin Capsicum Foam Procedure - Bunbury Hospital
This document defines the process for the use of Oleoresin Capsicum Foam (Pepper Foam) by Security Officers at the Bunbury Hospital.
Security Personnel - Patient Guarding and Surveillance Procedure
This document is intended as a guide for security including WA Country Health Service (WACHS) South West employees and external providers undertaking guarding or surveillance duties.
Security Personnel Duty Procedure - Goldfields Mental Health Service
This procedure is intended as a guide for nursing and medical staff when a security officer is undertaking security, guarding, or surveillance duties.
Security Procedure - Albany Hospital Acute Psychiatric Unit
The aim of this procedure is to ensure that patients receive optimal care and that services are provided in an environment that is appropriate and safe for both patients and staff.
Security Procedures Manual - Albany Health Campus
Albany Health Campus Security Department's primary role is to provide an effective and efficient Security Service to meet the needs of all health care providers.
Security Risk Management Policy
The purpose of the this policy is to outline the key aspects of personal and property security, and to assist health facilities to maintain an effective security program that is based on a security risk assessment of the facility and the introduction of protective security measures.
Sedation for Mental Health Patients Awaiting Aeromedical Transfer Guideline
This guideline has been developed to minimise the risk of adverse events related to the use of prolonged sedation for adult mental health patients in the WA Country Health Service (WACHS) who are awaiting transfer for specialist treatment. The medication options are designed to be simple to improve practicality of use and likely availability of medications within WACHS sites. It is designed for adults and should not be used for children. For paediatric patients, it is recommended to contact the consulting emergency department physician at Princess Margaret Hospital or Acute Response Team (ART).
Sedation Process for Mental Health Patients Flowchart
Flowchart for the sedation process of mental health patients. This process is subject to alteration dependent on clinical circumstances, reasons for which should be documented.
Shared Care of Mental Health Clients in Remote Area Settings Procedure - Kimberley
This procedure aims to ensure that services to mental health clients in remote settings in the Kimberley is a cooperative, coordinated and collaborative shared care approach between Primary Health Care services, Kimberley hospitals and the KMHDS.
Shared Care Relationships with Primary Care and Non-Government Providers - Ambulatory Care Setting Procedure
This procedure sets out the Mental Health Shared Care within the ambulatory care setting and refers to the philosophy of and arrangements for managing a client's journey as they enter and exit both public health and non-government services.
Shift Coordinator Procedure
This procedure sets out the roles and responsibilities of the Shift Coordinator.
Short Stay Observation Unit - Emergency Department Procedure - Busselton Health Campus
This procedure has been produced to facilitate patient flow through the Emergency Department (ED) and guide the operation of the Busselton Health Campus (BHC) ED Short Stay Observation Unit (SSOU) to reflect a 'good practice model' of care that meets BHC's local context.
Short Stay Unit Admission Criteria Procedure - Broome Hospital
This procedure sets out how early comprehensive multidisciplinary assessment and care of selected patients is provided, and how to optimise patient flow from the emergency department through the admission, to discharge and ongoing community care.
Short Stay Unit Procedure - Broome Hospital
The Short Stay Unit (SSU) is a four bed unit located on the Medical / Surgical Ward that aims to provide comprehensive, multidisciplinary patient-centred care and treatment over a designated period of up to 24 hours before discharge.
Short Stay Unit Procedure - Geraldton Hospital
The Geraldton Hospital Short Stay Unit provides short stay admission for the assessment and care of selected patients who no longer require active ED care. This procedure aims to optimise patient flow and bed utilisation by reducing the length of patient stay in ED.
Smoke Free WA Health System Policy Implementation Procedure
The WA Country Health Service (WACHS) is committed to reducing tobacco consumption and acknowledges it has a duty of care to provide smoke free environments that minimise exposure of patients, staff and visitors to the harmful effects of second hand smoke. This Smoke Free Procedure sets a positive example to the wider community, complimenting other health promotion messages.
Smokers Clinic Guideline - Great Southern Mental Health Service
The purpose of this document is to provide guidance for staff caring for patients accessing the Smokers' Clinic from their initial assessment to discharge, in order to effectively continue to address nicotine dependence in a supportive and evidence based manner.
Smoking and Nicotine Replacement Therapy Procedure - Broome Mental Health Inpatient Unit
Mabu Liyan /Broome Mental Health Unit (BMHU) supports the Smoke Free WA Health Policy and this document outlines the process in place around the partial exemption to the smoke free policy to allow involuntary patients the option to smoke tobacco in the grounds of the inpatient unit.
Smoking Care Guideline - Albany Hospital Acute Psychiatric Unit
The purpose of this document is to provide guidance for staff caring for patients on the Albany Acute Psychiatric Unit from their initial assessment to discharge and beyond, in order to effectively address nicotine dependence in a supportive and evidence based manner. All staff have a responsibility for their own health and the health of others on the ward by supporting compliance with this procedure.
Smoking Exemption Procedure - Goldfields Mental Health Inpatient Service
This procedure outlines how and where the partial exemption to the Smoke Free WA Health System Policy is to be managed at Goldfields Mental Health Inpatient unit.
Snakebite Management Guideline
This guideline provides direction to WA Country Health Service (WACHS) staff regarding best practice management of all snakebite cases. This document provides a general approach to snakebite management. Snakebite management with signs of envenomation should occur in conjunction with advice from Clinical Toxicologists via the Poisons Information Centre. The nation-wide number is 131126.
Social Media Policy
Social media is the term that describes web-based applications that enable the creation and exchange of user-generated online content. Examples of social media include Facebook, LinkedIn, Google+, Pinterest, YouTube, Tumblr and Twitter. This policy provides the standards for staff within WACHS to engage in communication using public-facing social media channels.
Special Referrals to Child Health Services Policy
This policy defines the roles and responsibilities of staff working across maternity, neonatal and child health services in relation to Special Referrals to Child Health Services (Special Referrals), to facilitate timely and effective transfer of information for families with known risk factors for the newborn or family.
Specialised Medication - Abatacept for ADULT Patients Guideline
Provides guidance for prescription and administration of Abatacept. This guideline must be used in conjunction with the associated mandatory MR173e Specialised Medication - Abatacept Pre-Infusion Checklist.
Specialised Medication - Ferric Carboxymaltose Guideline
This document provides guidance for the prescription and administration of ferric carboxymaltose (Ferinject) only, at sites which have been approved for its use. For pregnant or breast feeding patients, refer to the King Edward Memorial Hospital (KEMH) O&G Clinical Guidelines - Pharmacy and Medications - Adult Iron Polymaltose Guideline.
Specialised Medication - Infliximab Guideline
Provides guidance for the prescription and administration of infliximab for adult patients. It must be used in conjunction with the associated mandatory Pre-Infusion Checklist for Infliximab. Information in this guideline is applicable to Remicade and the biosimilar product Inflectra.
Specialised Medication - Intravenous Aminoglycosides for ADULT Non-pregnant Patients Guideline
This guideline outlines the process for the use of intravenous aminoglycosides in non-pregnant adults. For obstetric patients, refer to the Women and Newborn Health Service (KEMH) Guidelines. For Paediatric patients, refer to the Perth Children Hospital ChAMP Monographs
Specialised Medication - Intravenous Glyceryl Trinitrate in Critical Care Areas Guideline
This document provides guidance for the prescription and administration of glyceryl trinitrate for adult patients via the intravenous route for use within Critical Care Areas (only).
Specialised Medication - Intravenous Phosphate Supplementation in Adults Guideline
This document provides guidance for the prescription and administration of phosphate supplementation in adults via the intravenous route.
Specialised Medication - Intravenous Vancomycin in Adults Guideline
Vancomycin is a restricted antibiotic on the Statewide Medicine Formulary - Formulary One. Expert opinion should be sought where recommended on the formulary and include a documented plan for review of the antibiotic. The use in Febrile Neutropenia should be in accordance with EVIQ guidelines as per WACHS Cancer Institute NSW - Standard Cancer Treatments - eviQ - EUCP Policy.
Specialised Medication - Iron Polymaltose Guideline
Provides guidance for the prescription and administration of iron polymaltose. It must be used in conjunction with the associated MR173c WACHS Specialised Medication - Iron Pre Infusion-Consent Checklist
Specialised Medication - Lithium (Adult Patients) Guideline
This document provides guidance for the prescription and administration of lithium in adult patients, and should be used in conjunction with appropriate references e.g. Therapeutic Guidelines, Australian Medicines Handbook.
Specialised Medication - Natalizumab Guideline
This document provides guidance for the prescription and administration of natalizumab for adults. It must be used in conjunction with the associated mandatory Pre-Infusion Checklist for Natalizumab. Information in this guideline is specific to (Tysabri).
Specialised Medication - Phenytoin (Injectable) for Adult Patients Guideline
Provides guidance for the prescription and administration of phenytoin via the intravenous route for adult patients. For Paediatric Patients, refer to the Perth Children's Hospital - Phenytoin - Paediatric (accessible via HealthPoint).
Specialised Medication - Potassium Supplementation Policy
This policy describes the distribution, prescribing and administration of potassium formulations in the WA Country Health Service (WACHS).
Specialised Medication - Rituximab Guideline
Provides guidance for the prescription and administration of rituximab when being used for rheumatoid arthritis only. If rituximab is being used as an anti-neoplastic agent, please refer to the appropriate guideline for that specific indication. Information in this guideline is specific to Mabthera.
Specialised Medication - Tocilizumab Guideline
This guideline provides guidance for the prescription and administration of Tocilizumab for adult patients by infusion or subcutaneous injection. This guideline must be used in conjunction with the associated mandatory MR173F WACHS Specialised Medication - Tocilizumab Pre-Infusion Checklist.
Specialist Obstetrician Services Procedure - Albany Health Campus
The aim of this document is to serve as the blueprint that sets out the pathway identifying the conditions and situations that require the input of a Specialist Obstetrician. This will assist GPOs and other health care providers in determining when the input of a Specialist Obstetrician is required in the Albany Hospital, as a level 3 Neonatal and a level 4 Obstetrics Service provider.
Specimen Collection (including Phlebotomy) and Pathology Results - WACHS Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for specimen collection (including phlebotomy) and pathology results throughout the WA Country Health Service (WACHS).
Split Thickness Skin Grafts Clinical Practice Standard
This CPS has been endorsed for use by WACHS and should be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.
Staff Identification Procedure
The purpose of this procedure is to establish a system that provides constant and immediate identification of WACHS employees to patients, visitors and other employees.
Staff Immunisation Procedure - Wheatbelt
Management of a staff immunisation strategy is a requirement under the WA Health Health Care Worker Immunisation Policy, the National Safety and Quality Health Care Standards, and the National Health and Medical Research Council through the Australian Immunisation Handbook. This procedure aims to provide additional information to support the implementation of a comprehensive staff immunisation strategy in the Wheatbelt.
Staff Rent Recoveries Reconciliation Procedure
This procedure outlines the reconciliation process to be performed in order to determine that all deductions from employee salaries for rental recovery have been made and accurately reconciled.
Staffing for Service Continuity during Disruptions and Emergencies Policy
The WACHS is committed to supporting the WA Department of Health in its designated functions as a Hazard Management and Support Agency under the Emergency Management Act 2005. These responsibilities include the provision of health disaster management services during any emergency. WACHS has a legislated requirement to instigate procedures to guide a structured response to emergencies at local and regional levels. Title changed from Service Continuity by Clinical and Support Staff in Cyclones and Other Emergencies Policy. Policy reviewed and broadened to include advice from Industrial Relations.
Standard of Nursing Practice Guideline - Psychiatric Intensive Care Unit - Albany Hospital Acute Psychiatric Unit
Psychiatric Intensive Care Units (PICU's) are a mental health setting for individuals requiring higher levels of acute care. These individuals require intensive nursing support and interventions to contain and manage risk issues associated with acute presentations.
Statutory Health Professional Registration Policy
All WA Country Health Service (WACHS) health professionals engaged or intended to be engaged in professional practice, which requires statutory registration in Western Australia, are to demonstrate that they possess a license to practice having satisfied the requirements of the relevant statutory registration board.
Statutory Registration Monitoring Procedure
All WA Country Health Service (WACHS) nurses, midwives and allied health and health science professionals engaged or intended to be engaged in professional practice which requires statutory registration in Western Australia are to demonstrate that they possess a license to practice having satisfied the requirements of the relevant statutory registration board.
Sterile Water Skin Injections for Relieving Back Pain in Labour - Consumer Information Sheet
This information sheet provides information to the patient about the Intradermal Sterile Water Injections technique.
Stoma Management Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for faecal and urinary stoma management throughout the WA Country Health Service (WACHS).
Storage and Handling of Gas in Cylinders Procedure
This procedure relates to the safe use, handling and storage of portable gas cylinders and the training of employees who are required to work with such materials.
Storage and Spills of Anaesthetic Volatile Agents Procedure - Geraldton and Carnarvon Hospitals
This procedure relates to correct storage of anaesthetic volatile liquids and the minimisation of intoxication due to volatile spillage.
Storage of Sterile and Non-Sterile Supply within Clinical Areas Guideline
This guideline applies to storage environments where purchased sterile supplies, reprocessed sterile items and non-sterile stock are stored within clinical areas in healthcare facilities throughout WACHS. It outlines storage environments, imprest systems and transportation systems. See separate editable version of Appendix 2 (on the righ-hand side of the screen under Related Documents / Forms).
Strategy, Planning and Service Development Guideline
This guideline supports the WA Country Health Service (WACHS) Strategy, Planning and Service Development Policy, effective April 2017. It documents in more detail, the WACHS approach to developing integrated strategic, operational, business plans and clinical/health services plans which align with each other, including monitoring and evaluation requirements.
Strategy, Planning and Service Development Policy
This policy documents the WA Country Health Service (WACHS) approach to developing integrated strategic, operational and clinical services plans, including monitoring and evaluation requirements, and aims to demonstrate the governance and linkage between high level WACHS wide strategy development and levels of planning and service development.
Subcutaneous Medications and Palliative Care - Frequently Asked Questions and Trouble Shooting Information Sheet
Information for palliative carers caring for people in their homes.
Summary of Infection Prevention Personal Protective Equipment Requirements Information Sheet - Wheatbelt
Infection Prevention Person Protective Equipment Requirements
Supply and Management of Potassium Ampoules Procedure Midwest
The purpose of this procedure is to enhance the safe use, storage and distribution of intravenous potassium chloride.
Supply of Non-PBS Pharmaceutical or Other Medical Supplies to WACHS Outpatients Policy
This policy outlines the circumstances in which non-PBS drugs and other medical items are to be supplied either at cost, or at a subsidised cost to the patient. Medical items could include continence aids, food supplements, gloves, dressings etc.
Supply of Nutritional Supplements and Enteral Feeds Scheme
This procedure applies to all staff in the WACHS Kimberley region involved in the provision of care for patients requiring nutritional supplements and/or enteral feeds at home.
Supply of Pharmaceuticals or Other Medical Supplies Procedure - Great Southern Mental Health Service
This procedure outlines the criteria and approval processes required to authorise Southern Country Health Service Great Southern Mental Health meet the co payments for PBS pharmaceuticals, or pay for other medical supplies for patients of the service.
Supply of Welfare Assistance Procedure - Great Southern Mental Health Service
NSQHS 1.3.1 (v1); NSQHS 1.5.2 (v1); NSQHS 1.8.1 (v1); NSQHS 1.8.2 (v1); NSQHS 1.14.2 (v1); NSQHS 1.17.2 (v1); NSQHS 4.4.2 (v1); NSQHS 1.1 (v2); NSQHS 1.2 (v2); NSQHS 1.3 (v2); NSQHS 1.4 (v2); NSQHS 1.8 (v2); NSQHS 1.9 (v2); NSQHS 1.17 (v2); NSQHS 2.1 (v2); NSQHS 2.13 (v2); NSQHS 6.5 (v2); NSQHS 8.7 (v2); NSQHS 8.10 (v2);
Surgical Safety Checklist Policy
The WA Country Health Service (WACHS) supports the use of the WHO Checklist. It is designed to improve safety by focussing on anaesthetic safety practice, ensuring correct site surgery, avoiding surgical site infection and venous thromboembolism.
Surgical Services - Controlling Exposure to Surgical Plume Procedure - Geraldton and Carnarvon Hospitals
Surgical plume presents a potential hazard to all staff who are present within the operating room when energy-based devices are operating and releasing plume into the environment. All theatre staff must be familiar with the smoke evacuation equipment; Smoke collection devices and high filtration masks for high risk procedures.
Surgical Services - Theatre Booking Procedure - Geraldton and Carnarvon Hospitals
This procedure sets out the theatre booking process to ensure that the relevant staff are aware of the correct booking procedure both during and after hours.
Surgical Ward Lift Contingency Procedure - Bunbury Hospital
This procedure sets out the actions to be taken when a patient of the surgical ward needs to be transported to theatre for non-elective surgery in the event that both lifts at the Bunbury Hospital have become inoperable.

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TeleChemotherapy Guideline
This guideline provides recommendations for WA Country Health Service (WACHS) staff involved with the safe handling of cytotoxic drugs and the delivery of low risk systemic anti-cancer therapy (SACT) to medical oncology patients via video supervision.
Telecommuting Agreement Template
This agreements is a mandatory document for all telecommuting arrangements for WACHS staff.
Telecommuting Occupational Safety and Health Assessment
This assessment is mandatory for all telecommuting agreements fro WACHS staff.
Telecommuting Policy
This policy covers the requirements of telecommuting (working from home).
TGA Notification and Recall for Medical Devices Policy
Therapeutic Goods Administration (TGA) issued recalls and notifications relating to medical devices are to be managed in a consistent, effective, timely and accountable manner as described in this policy to ensure a safe healthcare environment.
The Doula as a Support Person Policy
A doula is a companion who understands the emotional and physical needs of a woman and her family throughout her pregnancy, labour, birth and early postnatal period, and provides continuous non-clinical support and non-clinical care for a woman throughout her whole experience. Doulas are usually engaged by women in a private fee for service arrangement. Choice of support person/s for labour, including a doula, is the woman's decision.
The Role of Ketamine in Acute Sedation of Adult MHP for RFDS Transfer Policy
This document seeks to clarify and standardise the use of Ketamine for the acute sedation of the agitated patient. It is to be used only by experienced practitioners who are familiar with the specific properties of Ketamine i.e. indications, contra-indications, side-effects and who are able to manage potential complications.
Therapeutic Infusion Process Flowchart
This flowchart sets out the process for referral, risk assessment and booking process for patients requiring therapeutic infusions in the WACHS South West.
Tonsillectomy-Adenoidectomy Care - Patient Discharge Information Sheet
Patient information sheet containing advice about care following discharge after tonsillectomy/adenoidectomy.
Tonsillectomy-Adenotonsillectomy (Paediatric) Policy
This policy ensures that higher risk patients are managed by those appropriately skilled and trained, and in appropriate facilities, a tonsillectomy, with or without adenoidectomy, may be performed on a paediatric patient in a WACHS hospital regionally approved for tonsillectomy.
Total Parenteral Nutrition Clinical Practice Standard
This CPS has been endorsed for use by WACHS and should be applied to the WACHS clinical practice context until it is transitioned completely to a WACHS CPS.
Travel Expenses and Reimbursement Guideline
This document outlines the standard / endorsed WACHS approach (along with alternatives) for staff purchasing accommodation and incidentals. It applies to travel where an allowance / reimbursement is applicable.
Travel Risk Assessment and Management Planning Procedure - Great Southern Population Health Unit
This Procedure applies only to the site named here
Triage, Assessment and Management in the Emergency Department - Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the triage, assessment, care and management of patients who present in an unplanned manner to WA Country Health Service (WACHS) emergency facilities.

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Unavailable Doctor - Obstetric Service Procedure - Bridgetown Hospital
This document explains the actions to be undertaken in the circumstances where it is known that a doctor accredited in obstetrics is unavailable (and therefore no obstetric service can be provided), for any patient at 37 weeks gestation or above, likely to birth during the relevant period is identified.
Use of Alcohol and Illicit Substances Procedure - Broome Mental Health Unit
This procedure ensures effective management of suspected alcohol or illicit substance use, which includes maintaining a safe environment.
Use of Electronic Equipment Mobile Telephones and Photographic Devices Procedure - Broome Mental Health Inpatient Unit
This document sets out the process to be followed to ensure that the taking of photograph, videos or use of equipment capable of making or sending a photographic image is not undertaken unless authorised by the Clinical Director or their delegate.
Use of Hand Held Radio Procedure - Geraldton Hospital
Correct use of hand held radio will provide a method for staff communication when staff are outside of the hospital building and remain on the hospital campus.
Use of Interpreter Services Procedure - Kimberley
This document provides information about the use of Interpreter services within the WA Country Health Service Kimberley.
Use of Non-Tear Garments Procedure - Broome Mental Health Unit
This procedure sets out the circumstances under which non-tear garments may be utilised within the Broome Mental Health Unit.
Use of Safe Room in Emergency Department Procedure - Broome Hospital
The purpose of this procedure is to provide guidance for the appropriate use of and to maximise safety in the use of Emergency Department Safe Room.
Use of TeleHealth for Mental Health Assessments and Examinations Policy
This policy outlines how videoconferencing is to be used when assessing or examining people detained under the Mental Health Act 2014 (WA) in the WA Country Health Service (WACHS). All relevant provisions of the Act, clinical practice standards and policies apply as if the patient were being assessed or examined in person.
Use of the Group Room Procedure - Albany Hospital Acute Psychiatric Unit
This procedure sets out the access and supervision requirements for use of the group room.
Use of the Secure Unit Family Meeting Room Procedure - Albany Hospital Acute Psychiatric Unit
This procedure sets out the steps which must be taken when planning an interview in the secure family interview room.
Utilisation of Interview Rooms Procedure - Broome Mental Health Inpatient Unit
This procedure ensures that all patient interviews are carried out in a safe environment.
Utilisation of the SHPA Clinical Competency Assessment Training Across WACHS Pharmacy Departments Procedure
In line with statewide recommendations, all WA Country Health Service (WACHS) regions are to utilise the SHPA clinCAT program for peer review and competency assessment of pharmacists.

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Vehicles Belonging to Patients Procedure - Broome Mental Health Inpatient Unit
Private vehicles parked on the grounds of the Broome Hospital (BH) campus are at the owner's risk and the hospital accepts no responsibility for the safety and security of vehicles parked on the campus. This procedure sets out how staff members (while not to drive a patient's vehicle) may assist with arrangements for removal from the Broome Hospital campus.
Venesection Procedure
The purpose of this document is to ensure that nursing staff are aware of the preadmission, procedural and discharge requirements when completing a therapeutic venesection on a patient. Only nursing staff working within their scope of practice may perform a venesection using venepuncture and cannulation techniques. This procedure is applicable to ADULT patients undergoing therapeutic venesection only.
Venous Thromboembolism Prevention Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management of prevention of venous thromboembolism (VTE) throughout the WA Country Health Service (WACHS).
Ventilation (Non-Invasive and Invasive Mechanical) - Clinical Practice Standard
This document will establish minimum practice standards for acute management of NIV and IMV throughout WACHS, primarily in the Emergency Department, awaiting transfer to a tertiary ICU.
Video Surveillance Policy
This policy sets out how video surveillance - defined as surveillance by a closed circuit television system for direct visual monitoring and/or recording of activities on premises or in a place, can be effective in reducing or preventing crime if it is part of a broader crime prevention and community safety strategy.
Videofluoroscopy Swallow Study Procedure
The purpose of this document is ensure the safe delivery of VFSS to adult patients, including competency, procedural and reporting requirements.
Visa Nomination Policy
The Visa Nomination Policy outlines: - Summary of the visa types under which WACHS can sponsor an applicant; Temporary Residence and Permanent Residence - Visa nomination fees and levies, payable by the sponsor (WACHS) - Required delegated authority to progress with a visa nomination - Roles and responsibilities of WACHS as an organisation, Workforce area/region/site, Visa Inbox Officer and the Registered Migration Agent.
Visitor Procedure - Albany Hospital Acute Psychiatric Unit
This procedure sets out how the Acute Psychiatric Unit staff are to facilitate and support patient access to people who will assist them in their recovery.
Vital Signs Procedure - Albany Hospital
The aim of this procedure is to provide guidance regarding the expected frequency of Vital Signs monitoring for all patients admitted to the Albany Hospital.
Volunteer Chaplaincy Services Photo ID Card Application Form - Albany Health Campus
The volunteer ID card issued remains the property of WACHS Great Southern and is to be returned to the Albany Hosptial on cessation of service.
Volunteer Policy
This policy applies to all persons engaged in paid and unpaid work in the WA Country Health Service (WACHS), and is to be read in conjunction with the WACHS HR Volunteer Screening Intranet page, which provides additional information on the process for volunteers and criminal record re-screening.
Vulnerable Patient Procedure - Broome Mental Health Unit
This procedure sets out how the Broome Mental Health Unit (Maby Liyan) is to comply with the National Standards for Mental Health Service to ensure that the optimal safety of the consumer is maintained and that they are protected from abuse and exploitation.

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WA Country Health Service Emergency Management Executive Sub-Committee - Terms of Reference
These are the Terms of Reference for the WA Country Health Service (WACHS) Emergency Management Executive Sub-Committee.
WA Country Health Service Executive Committee - Terms of Reference
The WACHS Executive Committee is the principal advisory body to the Chief Executive Officer (CEO) of WACHS and as such, assists with the management of WACHS by providing advice to the CEO on strategic service and policy issues. The Exec Committee collectively, is accountable and responsible for the strategic and operational leadership, management and performance of the WACHS.
WACHS Discipline Guide
The WACHS Discipline Guide is required to support the practical application of the Discipline Policy (MP 0127/20). It describes the process and steps to be followed in managing discipline matters.
WACHS Executive Sub-Committee Operations Procedure
This document been prepared with a view to setting out how the WACHS Committee framework is to operate, to provide appropriate oversight of WACHS operations to the Executive and its sub-committees, standardising committee procedures to improve consistency, effectiveness and accountability associated with committee functions, and outlining the roles and responsibilities of all parties and to provide guidance to Committee Executive Officer to ensure meeting outcomes are documented in a meaningful way.
WACHS Finance and Performance Executive Sub-Committee - Terms of Reference
The Finance and Performance Executive Sub-Committee is responsible to the WACHS Executive Committee. Its primary role is to provide oversight of organisational performance including Financial, Business, Service and Clinical.
WACHS Health Care Safety and Quality Executive Sub-Committee - Terms of Reference
The Health Care Safety and Quality Executive Subcommittee ensures care is consumer and carer centred, is driven by information, and is consistent with WACHS values. The committee leads for high performance, collaboration and continuous improvement and ensures that WACHS systems are organised for safety.
WACHS Information Governance Executive Sub-Committee - Terms of Reference
The IGC Executive Sub-Committee reports and makes recommendations to the WACHS Executive in line with the whole of Health ICT and IM Strategy, relevant policy and legislation. The committee provides governance and assurance over new ICT and BI requests, delivery of major ICT projects and utilisation, support and training for existing applications, data collections and BI reporting and analysis products
WACHS Infrastructure Steering Group - Terms of Reference
The Infrastructure Steering Group Executive Sub-Committee oversees, from a strategic context, infrastructure asset planning, asset procurement, asset operation and maintenance, and asset disposal requirements for WACHS. The group ensures compliance with relevant policies, guidelines and governance to ensure effective and consistent asset management, and infrastructure delivery functions across the organisation.
WACHS Interest Register (WIRe) Business Rules Policy
This policy provides the business rules concerning the recording and management of interest declarations in HP Records Manager.
WACHS Interest Register (WIRe) Flowchart - Wheatbelt
This flowchart reflects the WACHS Process Map Flowchart for WACHS Interest Register (WIRe), however encompasses Wheatbelt regional process to help guide staff with the correct recordkeeping practices.
WACHS Interest Register (WIRe) Process Map Flowchart
This flowchart sets out the process for the recording and management of interest declarations in HP Records Manager.
WACHS Kimberley-KAMS Co-Developed Clinical Guidelines EUCP in Kimberley Policy
This policy endorses the use of specified WACHS Kimberley / Kimberley Aboriginal Medical Service co-developed protocols/guidelines' in the Kimberley.
WACHS Patient Experience and Consumer and Carer Engagement Steering Group - Terms of Reference
The Executive Sub-Committee's role is to oversee the development, implementation and evaluation of the WACHS Patient Experience and Consumer and Carer and Community Engagement (PEaCCE) Strategy and Implementation Plan; and reporting and monitoring of the Implementation Plan.
WACHS Procurement and Contract Management Executive Sub-Committee - Terms of Reference
The WACHS Procurement and Contract Management Executive Sub-Committee reports and makes recommendations to the WACHS Executive in line with the WA Health Reform Program 2015-2020, the WA Health Strategic Procurement Program, and WACHS Strategic Directions 2015-2018. The committee provides governance and assurance over procurement and contract functions and activities.
WACHS Radiology Reporting Services Clinical Sub Committee - Terms of Reference
The RRS Clinical Sub Committee's role is to support clinical governance oversight of radiological reporting and procedural service providers and to enhance clinical performance and service development.
WACHS Regional Directors' Forum - Terms of Reference
The RDF is established to facilitate the contribution of Regional Directors to the effective and strategic management of delivering safe, patient focussed and quality health services.
WACHS Workforce Executive Sub-Committee - Terms of Reference
The Workforce Executive Sub-Committee is responsible to the WACHS Executive Committee. Its primary role is to lead workforce and organisational development strategy to contribute to enhanced organisational performance in line with WACHS Strategic Directions.
WACHS-SW Clinical Contracts Management Group - Terms of Reference
The purpose of the WACHS-SW South West Clinical Contracts Management Group is to ensure effective delivery of the services contracted by WACHS from St John of God Health Care (SJGHC) in the South West region through Clinical Services Agreements (CSA) and other contracts for clinical services and to ensure compliance with the requirements of the CSAs and contracts.
WACHS-SW Emergency Management Manual
This Emergency Management Manual (EMM) outlines the approach taken by the regions Emergency and Disaster Sub Committee (EDSC) for emergency operations. The Emergency Management Manual forms part two of the regions Emergency Management Plan (EMP). The Emergency Management Manual is designed to be read in conjunction with the Emergency Management Plan.
WACHS-SW Emergency Management Plan
This Emergency Management Plan (EMP) outlines the approach taken toward emergency management by the region's Emergency and Disaster Sub Committee (EDSC). This Emergency Management Plan is designed to assist the WA Country Health Service - South West (WACHS-SW) in its prevention, preparedness, response and recovery from emergency situations.
Ward Discharge Medication Flowchart - Bunbury Hospital
Ward discharge medication process for the Bunbury Hospital.
Warming Parenteral Fluids Clinical Practice Standard
The purpose of this policy is to establish minimum practice standards for the care and management of warming parenteral irrigation and intravenous fluids throughout the WA Country Health Service (WACHS).
Waste Management Policy
This policy sets out how WACHS is to manage and dispose of waste in accordance with Commonwealth and State legislation, the Department of Environment and Conservation, the Environmental Protection Authority, Government Policy, Local Government and Australian Standards.
Web Content Checklist - TYPO3
This checklist outlines the requirements for web page content and is to be used in conjunction with the WACHS Web writing guidelines and WA Health Web Guidelines. Compliance with this checklist is mandatory.
WebPAS Child at Risk Alert Procedure
The WA health system Guidelines for Protecting Children 2015, outlines the obligations of all WA Health employees to recognise and respond to health and safety concerns of children. WA Country Health Service (WACHS) staff need to take action whenever an unborn baby/infant/child has been identified as needing protection from harm arising from abuse and/or neglect.
Wheatbelt - Eastern District Medical Advisory Committee - Terms of Reference
These are the Terms of Reference for the Wheatbelt Eastern District Medical Advisory Committtee.
Wheatbelt - Southern District Medical Advisory Committee - Terms of Reference
These are the Terms of Reference for the Wheatbelt Southern District Medical Advisory Committtee.
Wheatbelt - Western District Medical Advisory Committee - Terms of Reference
These are the Terms of Reference for the Wheatbelt Western District Medical Advisory Committtee.
Wheatbelt Audit and Risk Sub-Committee - Terms of Reference
These are the terms of reference for the WACHS Wheatbelt Audit and Risk Sub-Committee which has overall responsibility for the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the region's activities (both clinical and non-clinical), that supports the achievement of the WACHS Wheatbelt's objectives.
Wheatbelt Clinical Governance and Patient Safety Sub-Committee - Terms of Reference
The CGPSSC has been established to provide strategic leadership and promote the region's integrated clinical governance system to staff to facilitate excellence in clinical care, to maintain and improve the reliability of systems and processes to improve quality of patient care and patient outcomes, to identify new opportunities for improvement and facilitate a culture of risk management and continuous improvement in clinical practice and patient safety, to ensure clinical audits follow a systematic process that improves quality of patient care by comparison with to current best practice and modification where necessary, and to share lessons learnt from clinical events.
Wheatbelt Community Mental Health - Case Review Meetings and Client Review Procedure
All clients of the Wheatbelt Community Mental Health Service service are to receive regular review of their care in a multidisciplinary team (MDT) format. This procedure details the requirements of clinical review meetings, which provide the means by which assessment and intervention for clients is planned and evaluated.
Wheatbelt Community Mental Health - Clinic Security - Open and Lock-up Procedure
This procedure informs staff about site security, including who is to operate alarm systems - how and when.
Wheatbelt Community Mental Health - Medication Recording in Patient Record Procedure
This procedure sets out how accurate records of psychotropic medications prescribed by the Wheatbelt Mental Health Service are to be kept, as well as any adjustments made due to side effects, ineffectiveness, or patient choice to keep an up-to-date medication record.
Wheatbelt Community Mental Health - Unexpected Death of a Client - Service Reporting and Support Procedure
This procedure sets out how the death of a client is formally reported, ensuring both the client's family and staff are involved, and are offered and receive appropriate support.
Wheatbelt Executive Committee - Terms of Reference
These are the Terms of Reference for the WACHS Wheatbelt Exectutive Committee.
Wheatbelt Information Governance Sub Committee - Terms of Reference
The Wheatbelt IGC is responsible to the Wheatbelt Executive Committee and its primary role is to ensure that: - Wheatbelt Information Management (IM) and Information Communications Technology (ICT) investments are aligned with WACHS business strategy and deliver maximum value - major ICT and IM projects are governed effectively and risks are managed - ICT and IM systems function effectively to support service delivery - oversight of WACHS Wheatbelt's development, implementation and evaluation of ICT and IM strategies and activities which facilitate the creation and maintenance of clinical and corporate information and communication systems - the collection and storage of information for strategic, operational and service improvement purposes is supported.
Wheatbelt Mental Health - Regional Team Meeting - Terms of Reference
This document sets out the terms of reference for the Wheatbelt Mental Health - Regional Team Meeting.
Wheatbelt Mental Health Patient Safety and Quality Network - Terms of Reference
The purpose of the Wheatbelt Mental Health Patient Safety and Quality (MHPSQ) Network is to provide a formal process for input into clinical and corporate governance to ensure optimal clinical services are provided within the constraints of the available human, financial and physical resources.
Wheatbelt Mental Health Service Leadership Team - Terms of Reference
The purpose of the Wheatbelt Mental Health Leadership Team (WMHLT) is to implement WACHS policy and where required, develop local procedures, to implement WACHS health reform agendas, provide leadership, manage, develop and coordinate the programs, functions and services of the WMHS, ensure optimal client services are provided within the constraints of the available human, financial and physical resources and to be a forum for resolving safety, quality and risk issues.
Wheatbelt Regional Infection Prevention Network - Terms of Reference
Terms of reference for the The WA Country Health Service Wheatbelt Regional Infection Prevention Network (WRIPN).
Wheatbelt Regional Learning and Development Network - Terms of Reference
The RL&DN exists to support the development of the Learning and Development (L&D) Annual Operational Plan based on identified education-based risks and the key clinical and corporate training and education priorities. The group will undertake a variety of relevant data analysis functions and provide a regular report on all aspects of L&D activity via the governance sub-committees to the Wheatbelt Executive Team, in addition to reporting and making recommendations to the Workforce Executive Sub-Committee in line with WACHS Strategic Directions.
Wheatbelt Workforce Governance Sub-Committee - Terms of Reference
The WACHS Wheatbelt Workforce Governance Sub-Committee is responsible to the WACHS Wheatbelt Executive Committee. Its primary role is to lead best practice and innovative workforce planning and organisational development strategies to contribute to enhanced organisational performance in line with WACHS and WACHS Wheatbelt Strategic Directions.
WMHS and GSMHS - WMHS Southern Wheatbelt Integration Project Working Group - Terms of Reference
The purpose of this committee is to provide operational and logistical oversight and governance of the relocation of NCMHS and its integration with WMHS.
Workers' Compensation and Injury Management System
All sections within this document have been superseded (see documents under their individual titles) EXCEPT the Injury Management Procedure.
Workers' Compensation Claims Management Procedure
Return to work is a fundamental objective of the Western This procedure sets out the responsibilities of all those within the process underlying the lodgement and management of workers' compensation claims for WACHS.
Workforce Learning and Development Policy
The WA Country Health Service (WACHS) aims to provide a learning and development framework that provides for the delivery of safe, high quality, consumer centred care and service. We achieve this through supporting and facilitating learning programs that provide for the development and maintenance of professional skills through contemporary workforce education and learning. Ensuring ongoing skills development and continuous learning assists us to attract and retain a workforce whose skills and capability grow in line with service needs.
Working Alone - Community Visiting - Goldfields Mental Health Service
The purpose of this procedure is to ensure that staff are provided with a safe workplace regardless of location or level of supervision, the clinical and physical environment in which care is to be delivered must be assessed with possible risks identified and managed.
Working Alone - SPOT GPS Tracker Cheat Sheet
Quick guide to using the SPOT GPS Tracker.
Working Alone - SPOT GPS Tracker Programming Procedure
This document relates to staff who require the ability to send GPS Coordinates based on a risk assessment. It informs users how to program the SPOT GPS tracker.
Working Alone - SPOT GPS Tracker User Reference Guide
This document (should be available for reference in the glovebox of the vehicle being travelled in) describes how to use and activate the SPOT GPS tracker.
Working Alone - Staff Movement Sheet
Record sheet for staff home visiting movements/schedules.
Working in Isolation - Minimum Safety and Security Standards for all Staff Policy
The purpose of this policy is to define the requirements and establish minimum safety and security standards for all staff working in isolation or alone throughout the WA Country Health Service (WACHS).
Working with Visual Display Units (VDUs) - Information Sheet
This is a guide for people who work with visual display units. It answers questions about VDUs and health and suggests some simple adjustments that users can make to workstations and screens to make them more comfortable and easy to use.
Workplace Ergonomics Guideline
This guideline is part of the hazard management element of the WACHS safety management system and is designed to ensure that a consistent, consultative risk management approach is applied to workplace ergonomic safety risks within all workplaces in WACHS.
Workplace Inspection Guideline
The WA Country Health Service (WACHS) is committed to providing a safe place of work for its employees, contractors and visitors. This document has been designed to provide guidance for Managers, Safety and Health Representatives (SHRs), workers and those responsible for WACHS sites on the workplace inspection process at WACHS.
Workplace Violence Risk Assessment Form
Workplace Violence Risk Assessment Work Sheet. (Editable versions of the Workplace Violence Risk Assessment Form and Safety Improvement Action Plan (SIAP) available via 'Related Forms' to the right.)

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X-Ray Operator General X-Ray Examination Assessment Form
X-Ray Operator General X-Ray Examination Assessment Form

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Zuclopenthixol Acetate (Clopixol Acuphase) Monitoring Guideline
This guideline sets out how Zuclopenthixol acetate (Clopixol Acuphase) - an intermediate acting intramuscular injection, indicated in managing acute psychosis or mania in adults, is administered in a Mental Health Inpatient Unit (only).

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