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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 Spinal Injury 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.
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 and Management of Mental Health Patients to General Inpatient Wards Procedure - Kalgoorlie Hospital
This Procedure applies only to the site named here
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 Pathway 1 - New Volunteer Flowchart
This Criminal Record Screening process applies to new Aged Care volunteers.
Aged Care CRS Pathway 10 - Employee Rescreening Flowchart
This process applies to the CRS rescreening of Aged Care employees.
Aged Care CRS Pathway 2 - Volunteer Rescreening Flowchart
This process applies to new volunteers for Aged Care Criminal Record Screening (ACCRS) rescreening.
Aged Care CRS Pathway 3 - Volunteer Not Meeting Requirements Flowchart
This process applies to new Aged Care volunteers who do not meet the Aged Care Criminal Record Screening (ACCRS) requirements.
Aged Care CRS Pathway 4 - New Employee Flowchart
This process applies to all new Aged Care employees.
Aged Care CRS Pathway 5 - Termination Process for New and Existing Employees Flowchart
This process applies to all employees who have not demonstrated evidence of their application for an Aged Care Criminal Record Screening (ACCRS) Check.
Aged Care CRS Pathway 6 - Reporting Process Flowchart
This process applies to employees not meeting Aged Care Criminal Record Screening (ACCRS) screening requirements.
Aged Care CRS Pathway 7A - Contractors Flowchart
This Criminal Record Screening process applies to Contractors who provide care to Aged Care recipients.
Aged Care CRS Pathway 7B - Existing Contractors - Interim Arrangements Flowchart
This process applies to existing contractors (providing care to Aged Care recipients) as an interim arrangement.
Aged Care CRS Pathway 8 - New Employee-Prospective Employee Not Meeting Requirements Flowchart
This process applies to Employees/ Prospective Employees where the Aged Care Criminal Record Screening (ACCRS) screening results return is negative.
Aged Care CRS Pathway 9 - Grievance Procedure Flowchart
Grievance procedure for Aged Care negative Criminal Record screening results.
Aged Care CRS Template - Termination Letter - Not Meeting Requirements
Template: Termination letter (when not meeting requirements) - new/prosepective employee / volunteer.
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.
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.

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