Medical/Dental Professionals

February Updates: Policies

Below are the new and revised policies that affect providers at Kaleida Health. Please take a moment to review this month's updates. The policy links below are accessible from a Kaleida Health computer only or when connected to the Kaleida Health network. For additional assistance, please contact Amber Mata at


  • SS.72 – Invasive Procedure Fire Risk Assessment and Mitigation Plan


  • IAC.25 – Image or Audio Recording for Medical, Legal, Teaching or Research Purposes – Added “audio” throughout
  • LE.10 – Treatment of Unemancipated Minor – Added statement that the providers conversation with the consenting party must be witnessed by a member of the Kaleida Health staff and that witness should be documented in medical record
  • RM.11 – Patient Transfer and Medical Screening – Added statement in transfer section about risks/benefits of transfer
  • MAT.1 – Soft Cup Vacuum Extraction During Delivery – Added section for caution with use of vacuum extraction
  • MAT.90 – Cervical Ripening with prostaglandin E1 (Misoprostol) or prostaglandin E2 (Cervidil) – Minor change to work instructions
  • TS.3 – Outpatient Transfusion Therapy- Adult – Detail clarifications made
  • TX.IVs&MEDS.19 – Nursing Practice in Administration of Drugs Intravenously – Adult Patients – Minor change, including addition of Advance Practice Practitioners
  • TX.IVs&MEDS.18 – Anticoagulation Management – Changes made to appendix
  • TX.NEURO.2 – Alteplase Administration for Acute Ischemic Stroke – Minor change related to documentation of behavior/affect in EMR