Table of Contents DME

Our policy manual comes to you ready for your own company logo, name, address. 
 Completely Customizable, making it yours!

Advance Directives

About "Advance Directives"

Foregoing or Withholding Life-Sustaining Treatment and/or Resuscitation

Authorization to Treat/Informed Consent

Authorization/Agreement for Services Form

Authorization to Treat Form - Mechanical Ventilator

Authorization to Treat Form - Apnea Monitor

Authorization to Treat Form - Enteral Nutrition Equipment

Client Bill of Rights Policy

Client Bill of Rights and Responsibilities

Code of Ethics

Ethics Committee

Confidentiality of Client Information

Confidentiality Statement Form - Staff

Conflict in Care

Conflict of Interest

Experimental Treatments

Client Concerns/Grievances

Client Perception of Care Report Form

Client Concerns/Grievance Process Flowchart

Non-English Speaking Clients - Cultural Considerations

Photographing/Videotaping Clients

Authorization and Consent Form - Photograph and Publication

Sensory Impaired Clients

Identification of Person(s) Responsible for Care, Treatment and Service Delivery

Clinical Decision-Making and Financial Incentives

CMS Medicare DMEPOS Supplier Standards



Acceptance Policy

Assignment of Staff

Referral Process

Referrals to Other Organizations/Individuals

Assessment of Clients

Physical Assessment - Respiratory Services

Order Intake Form

Client Abuse - Adult

Client Abuse - Child

Suspected Adult or Child Abuse Report Form

Planning Care, Treatment and Services

Plan of Care

Plan of Treatment

Plan of Treatment Form

Plan of Care Form

Plan of Care Forms:

Oxygen Equipment

Respiratory Equipment

Apnea Monitor Equipment

Ventilator Equipment

Infusion Pump Equipment

Plan of Care Forms

Providing Care, Treatment and Services

Coordination of Services

Client Emergency

Clinical Respiratory Services

Death in the Home

Follow-up Visits

Nutritional Product Storage

Medical Supervision

Oxygen Delivery Systems

Oxygen Concentrator Training Checklist

Oxygen Concentrator Maintenance Checklist

Required Emergency Backup Oxygen System for Concentrator Clients Consent Form

Pentamidine Aerosol for Treatment of Pneumocystis Carinii Pneumonia

Traction and Related Traction Services

Physician's Prescription

Physician's Telephone Orders

Confirmation of Physician's Orders Form


Pre-discharge Visits to Clients in Hospital

Pulse Oximetry

Specimen Collection

Telephone Order Taking            
Telephone and Communication Log

Tracheostomy Care


Multidisciplinary Client Education

Client Instruction

Aerosol Therapy

Aerosol Therapy Training Certification Form

Aspiratory (Suction Unit)

Aspirator (Suction Unit) - Installation and Assembly Instructions

Cardiopulmonary Resuscitation

Disinfection of Respiratory Breathing Circuits - Instructions

Home Equipment - Instructions Checklist

Humidifier Cleaning Instruction

Postural Drainage Therapy

Respiratory Client Education

CPAP/BiPAP Client Orientation Checklist

IPPB Training Certification Form

Clients Who Smoke with Oxygen in Use

Minor Troubleshooting - Oxygen Concentrator

Nasotracheal and Tracheostomy Suctioning

Suction Training Instructions Form


Discharge Policy

Discharge Summary

Discharge Worksheet

Discontinuance of Service Against Medical Advice Form

Home Care Services Discharge Summary Form

Transfers to Other Organizations


Medication Administration and Transcription

Medication Profile Form "A"

Medication Profile Form "B"

Medication Administration Record Form

Medication Management - Clinical Respiratory Services

Medication Orders for Clinical Respiratory Therapy

First Dose Medications

Drug Reactions

Investigational Medications


Infection Control

Infection Control Definitions

Identification and Reporting of Infectious Diseases

Standard Precautions

Hand Hygiene

Personal Protective Equipment

Personnel Guidelines for Use of Personal Protective Equipment

Bloodborne Pathogens Exposure Control

Report of Exposure to Bloodborne Pathogens Form

Bloodborne Pathogens - Post-Exposure Evaluation and Follow-up

Hepatitis B Vaccination Policy

Employee Health - Employee Illnesses

Infection Control Plan

Infection Risk Assessment

Exposure Control Plan

Organizational Plan and Response to a Potential or Actual Infectious Pandemic Outbreak

Pandemic Risk Assessment Tool for Home Care Organizations Policy

Pandemic Infection Outbreak Planning and Preparedness Risk Assessment Tool for Home Care Organizations


Organizational Performance Improvement Plan

Durable & Home Medical Equipment - PI Monitoring and Evaluation Plan

Durable & Home Medical Equipment - PI Trending Sheet

Durable & Home Medical Equipment - PI Outcome Evaluation

Durable & Home Medical Equipment - PI Volume Measures/Statistics

Performance Improvement Reporting Form

Performance Improvement Committee Minutes Form

Corrective Action Plan Form

Annual Company Evaluation

Incident Reporting

Incident Report Form

Performance Improvement Department Notification Form

Product Incident Reporting

Product Incident Report Form

Perception of Care/Satisfaction Surveys

Perception of Care/Satisfaction Survey Form

Sentinel Event Review

Root Cause Analysis Flowchart

Self-Evaluation of Service

Home Care Medical Services Self-Evaluation Diagram


Scope of Service

Services Provided - Hours of Operations

On-Call Services

Geographical Service Area

Medical Advisor

Communication of Information

Client Safety Program

Organization and Structure

Local Management and Administration (for Companies with Multiple Locations, Satellite Offices, etc.)

Governance - Board of Directors/Management Company

Governance - Sole Proprietorship

Annual Operating Budget and Capital Expenditure Plan

Professional Advisory Committee

Physician License Verification

Staff Recruitment, Retention and Education

Contracted Services

Role of Leadership in Performance Improvement

Registration Process - Sterilizer of Bedding and Upholstered Furniture


Environmental Safety

Employee Safety/Security

Employee Job-Related Injuries

Electrical Safety Release Form

Safety Hazard Surveillance

Security Plan

Hazardous Materials and Waste Plan

Hazardous Materials Emergency Response Communication

Identification, Handling and Disposal of Hazardous Materials

Emergency Management Plan

Bomb Incident Plan

Bomb Threat Report Form

Detecting Suspicious Packages/Letters

Natural Disaster Management Plan

Terrorism Response Plan

Hazard Vulnerability Analysis

Emergency Management - Hazard Vulnerability Analysis Worksheet

Fire Safety

Fire Drill Report 

Safe Medical Devices

Medical Device Problem and Recall

Utility Systems Management Plan

Lockout/Tagout Procedures

Lockout/Tagout Training

Equipment Delivery/Receipt

Entering the Client's Residence

Equipment Set-up Procedure

After-Hours Delivery

Backup Equipment

Delivery Procedure

Delivery Invoice

Receiving Equipment

Sample Tags

Pick-up Procedure

Equipment and Bed Cleaning Guidelines

Equipment Maintenance and Repairs

Non-Routine (Non-PM) Equipment Maintenance Record

Preventive Maintenance - Apnea Monitors

Nebulizer/Compressor Service / CPAP/BiPAP Service Form

Preventive Maintenance - Feeding Pump

Preventive Maintenance - Oxygen Regulators

Vendor Repair Service

Equipment Warranty Policy

Return of Purchased or Rental Equipment

Delivery Route Sheet Form

Service Call Report Form


Vehicle Policy

Compliance with DOT Laws

Insurance Coverage for Employee-Owned Vehicles

Motor Vehicle Accidents

Motor Vehicle Accident Report by Driver Form

Point System for Vehicle Accidents and Moving Violations

Company Driver - Motor Vehicle Violation Report Certification

Company Driver - Motor Vehicle Violation Report Certification Form

Restrictions Regarding Vehicle Use

Drivers Transporting Compressed Medical Gases (CMG)

Vehicle Markings and Appearance

Vehicle Files

Vehicle Maintenance/Repairs

Vehicle Preventive Maintenance Schedule Log

Outfitting Vehicles Containing Liquid Storage Units Used for Transfilling (Stationary, Portable or Vehicle Units)

Vehicles Used to Transport High-Pressure Medical Gas

Operation Assessments and Hazardous Manifest Form

Bill of Lading (Hazardous Manifest) Form

Driver's Vehicle Use (Driving) Competency Evaluation Form

Sample of Your State/County "Written Examination for Drivers"

Compressed Medical Gas (Oxygen)

Compressed Medical Gas Compliance Regulations

Oxygen Equipment Standards

Compressed Medical Gas Record Keeping

Oxygen/Combustible Gas Storage

Delivery of Compressed Gas Cylinders to Client's Home

CMG Cylinder Delivery Record Form

Oxygen Tracking Log

Batch Quality Control Log - Liquid Oxygen

Assigning Batch and/or Lot Numbers

Equipment Calibration

Oxygen Analyzer Calibration Record Form

Scale Calibration Record Form

Inspections by FDA

Liquid Oxygen FDA Regulation Compliance Checklist

Master Control Record - Bulk Tank Oxygen Test

Labeling Procedure

Liquid Oxygen Sample Batch Record Tag

Sample Precautionary Label - Liquid Oxygen

Receiving Procedure for Liquid Oxygen and High-Pressure Gas from Supplier (Not for Bulk Locations)

Oxygen Testing Procedures Bulk Tank Locations - New Shipment

Transfilling Guidelines - Oxygen Cylinder

Hydrostatic Testing Standards

Oxygen Cylinder Pre-Fill Procedure

Oxygen Testing Procedures When Transfilling Cylinders - Compressed Gas (High Pressure)

Transfill Record Form - Compressed Gas Cylinder

Oxygen Transfill Inspection Report Form

Oxygen Testing Procedures for Liquified Gas in Vehicle Storage System

Filling (Liquid Oxygen) Portable Cryogenic Vessels from Bulk Storage or Vehicle Storage Systems

Filling of Vehicle Storage System

Handling Oxygen Products Which Do Not Meet Specifications

Compressed Medical Gas Storage - Cylinders

Oxygen Storage (Bulk)

Refrigerated Liquid Oxygen Form

Portable Gas Cylinders Form

E Cylinders Flow Chart


Position Description/Performance Evaluation - DME Operations Manager

Performance Evaluation - Age-Related Competency - DME Operations Manager

Annual Competency Clinical Skills Assessment - DME Operations Manager

Position Description/Performance Evaluation - DME Customer Service Supervisor

Performance Evaluation - Age-Related Competency - DME Customer Service Supervisor

Annual Competency Clinical Skills Assessment - DME Customer Service Supervisor

Position Description/Performance Evaluation - DME Customer Service Representative

Performance Evaluation - Age-Related Competency - DME Customer Service Representative

Annual Competency Skills Assessment - DME Customer Service Representative

Position Description/Performance Evaluation - DME Billing Collection Coordinator

Annual Competency Skills Assessment - DME Billing Collection Coordinator

Position Description/Performance Evaluation - DME Receptionist

Performance Evaluation - Age-Related Competency - DME Receptionist

Annual Competency Skills Assessment - DME Receptionist

Position Description/Performance Evaluation - DME Marketing Representative

Annual Competency Skills Assessment - DME Marketing Representative

Position Description/Performance Evaluation - DME Respiratory Care Supervisor

Performance Evaluation - Age-Related Competency - DME Respiratory Care Supervisor

Annual Competency Clinical Skills Assessment - DME Respiratory Care Supervisor

Position Description/Performance Evaluation - DME Warehouse Supervisor

Performance Evaluation - Age-Related Competency - DME Warehouse Supervisor

Annual Competency Skills Assessment - DME Warehouse Supervisor

Position Description/Performance Evaluation - DME Driver/Service Technician

Performance Evaluation - Age-Related Competency - DME Driver/Service Technician

Annual Competency Skills Assessment - DME Driver/Service Technician

Staff Selection

Current Licensure, Certification and Registration

Staff Orientation Checklists

Orientation Checklists:


Office Staff

Driver/Service Technician

Home Care Clinical Staff

Respiratory Care - Competency Checklist

Infusion Therapy - Competency Checklist

Inservice and Continuing Education

Continuing Education Attendance Record Form

Inservice Attendance Record Form

Performance Evaluations

Applications for Employment


Information Management Plan

Privacy and Confidentiality of Information

Unacceptable Abbreviation and Symbol List

Approved Symbols and Abbreviations List

Client Record Policy

Client Record Home Care Notes Form

Client Information Form

Medical Record Audits

Durable Medical Equipment Medical Records Audit Form

Durable Medical Equipment Record Review Summary Form

Answering Service

  Terms           Report Abuse           Print page             Remove Access  |  
Powered by Google Sites

The Compliance Doctor's DME Manual of Policies and Protocols