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About the Region
Policies and Procedures: Region Wide

Region-wide policies and procedures are organized according to these categories:

00 - Introduction
10 - Organization
20 - General Information
25 - Information Technology and Telecommunications
30 - Human Resources
40 - Financial
50 - Legal
60 - Client Care
75 - Records and Reports
80 - Emergency Preparedness
95 - Facilities Services
100 - Research

Table of Contents​ 

​​In​ addition to SHR policies, the following directives are currently in effect:

There are no directives in effect at this time.

Please Note:

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collapse Category : 000 - Introduction ‎(2)
Policies and Procedures7311-00-001.pdf7311-00-00119-Mar-09
Policies Handbook7311-00-001-Handbook.pdf7311-00-001-Handbook19-Mar-09
collapse Category : 010 - Organization ‎(6)
Code of Conduct7311-10-001.pdf7311-10-00106-Nov-08
Enterprise Risk Management7311-10-005.pdf7311-10-00516-Apr-14
Fraud7311-10-002.pdf7311-10-00216-Apr-14
Naming Policy7311-10-004.pdf7311-10-00409-Nov-16
Our Values in Action7311-10-001-Our-Values.pdf7311-10-001-Our-Values06-Nov-08
Speaking Up - Protection of Persons Reporting Wrongdoing7311-10-003.pdf7311-10-00317-Jan-11
collapse Category : 020 - General Information ‎(20)
Acute Care Bed Occupancy Charge for Refusal to Leave an Acute Care Bed7311-20-021.pdf7311-20-02120-Sep-16
Carbon Monoxide Monitoring and Reporting7311-20-020.pdf7311-20-02017-Jul-13
Client, Family and Community Member Engagement7311-20-016.pdf7311-20-01630-Nov-12
Clinical Health Record Form Standards7311-20-002.pdf7311-20-00219-Dec-16
Competitive Bidding7311-20-007.pdf7311-20-00702-Apr-12
Emergency (Flash) Sterilization7311-20-015.pdf7311-20-01526-Jun-09
Facilitation of Smudging Ceremonies7311-20-004.pdf7311-20-00405-May-16
Interpretation and Translation Services7311-20-013.pdf7311-20-01316-Mar-17
Interpretation and Translation Services - Appendix A7311-20-013-Appendix-A.pdf7311-20-013-Appendix-A31-Aug-15
Management of Patient/Client/Resident/Family Concerns/Complaints7311-20-003.pdf7311-20-00329-Jun-11
Management of Recall Notices and Alerts7311-20-010.pdf7311-20-01025-Sep-07
Open Family Presence7311-20-018.pdf7311-20-01812-May-16
Provincial Procurement7311-20-008.pdf7311-20-00822-Oct-15
Provision of Snack Food and Beverages Vending Services7311-20-012.pdf7311-20-01201-Apr-03
Safekeeping of Patient/Client Valuables7311-20-005.pdf7311-20-00505-Jun-00
Social Media7311-20-017.pdf7311-20-01721-Feb-12
Standards for Development of Clinical Health Record Forms - Appendix A7311-20-002-Appendix-A.pdf7311-20-002-Appendix-A19-Dec-16
Tobacco and Smoke-Free Workplace Policy 7311-20-001.pdf7311-20-00101-Jul-15
Vendor Visitation and Conduct7311-20-011.pdf7311-20-01122-Oct-15
Waste Management7311-20-019.pdf7311-20-01918-Jan-13
collapse Category : 025 - Information Technology and Telecommunications ‎(12)
Disposal Of IT Assets7311-25-006.pdf7311-25-00624-Aug-12
Email Acceptable Use7311-25-001.pdf7311-25-00110-Mar-15
Emailing Personal Health Information7311-25-005.pdf7311-25-00510-Mar-15
Internet Acceptable Use7311-25-002.pdf7311-25-00230-May-13
IT Security7311-25-000.pdf7311-25-00025-Jun-14
IT Security Incident Management7311-25-010.pdf7311-25-01001-Aug-14
IT Systems - Monitoring Access and Use7311-25-009.pdf7311-25-00901-Aug-14
Password Policy7311-25-003.pdf7311-25-00329-Nov-13
Remote Access7311-25-008.pdf7311-25-00801-Aug-14
Security Of Mobile Devices And Removable Media7311-25-007.pdf7311-25-00724-Aug-12
SHR User Account Policy7311-25-004.pdf7311-25-00430-May-13
Wireless Access7311-25-011.pdf7311-25-01101-Aug-14
collapse Category : 030 - Human Resources ‎(17)
Attendance Policy7311-30-014.pdf7311-30-01429-Jun-11
Career Milestones7311-30-021.pdf7311-30-02116-Mar-17
Conflict of Interest7311-30-005.pdf7311-30-00516-Mar-17
Criminal Record Screening7311-30-006.pdf7311-30-00602-Apr-12
Duty to Accommodate7311-30-018.pdf7311-30-01816-Jun-15
Learner Placements7311-30-020.pdf7311-30-02008-Mar-17
Maintenance of Professional Registration/Licensing for Out of Scope Employees7311-30-011.pdf7311-30-01101-Dec-16
Management of Employees, Physicians and Other Health Care Workers During Influenza Outbreaks in Health Care Facilities7311-30-017.pdf7311-30-01715-Oct-07
Professional Appearance and Dress Code7311-30-013.pdf7311-30-01319-Feb-08
Representative Workforce7311-30-012.pdf7311-30-01230-May-13
Respectful Workplace7311-30-001.pdf7311-30-00125-Aug-17
Retirement Recognition7311-30-015.pdf7311-30-01501-Sep-16
Terms and Conditions of Employment - Out of Scope Employees7311-30-010.pdf7311-30-01030-May-13
Vacation Usage, Carry-Over and Payout7311-30-004.pdf7311-30-00401-Dec-16
Violence Management7311-30-007.pdf7311-30-00706-Dec-13
Workplace Harassment7311-30-022.pdf7311-30-02225-Aug-17
Workplace Safety7311-30-002.pdf7311-30-00220-Jul-12
collapse Category : 040 - Financial ‎(5)
Investment Policy7311-40-003.pdf7311-40-00317-Nov-10
Investment Policy Addendum7311-40-003A.pdf7311-40-003A29-Jun-11
Purchasing Cards 7311-40-004.pdf7311-40-00408-Feb-13
Purchasing Cards - Appendix A: User Guide7311-40-004-User-Guide-Appendix-A.pdf7311-40-004-User-Guide-Appendix-A08-Feb-13
Signing Authority Financial Committments7311-40-002.pdf7311-40-00230-Mar-09
collapse Category : 050 - Legal ‎(9)
Consent / Informed Consent7311-50-002.pdf7311-50-00229-May-15
Copyright7311-50-005.pdf7311-50-00516-Apr-14
Critical Incident Reporting7311-50-008.pdf7311-50-00801-May-17
Disclosure7311-50-009.pdf7311-50-00901-May-17
Informed Consent for Blood Components and/or Plasma Protein Products, Including Tissue Graft Transplantation7311-50-004.pdf7311-50-00409-Feb-17
Intellectual Property7311-50-010.pdf7311-50-01010-Feb-14
Safety Reporting7311-50-006.pdf7311-50-00601-May-17
Suspected Child Abuse7311-50-007.pdf7311-50-00727-Jun-16
Suspension of Privileges - Incomplete Health Records7311-50-003.pdf7311-50-00301-Nov-94
collapse Category : 060 - Client Care ‎(27)
Advance Care Directives7311-60-005.pdf7311-60-00501-Sep-98
Allergy/Intolerance Documentation7311-60-029.pdf7311-60-02917-Jul-13
Application of Non-Invasive Ventilation for Acute Respiratory Failure7311-60-024.pdf7311-60-02430-Nov-12
Delegation of a Medical Activity to a Registered Nurse7311-60-003.pdf7311-60-00319-Dec-16
Ethics Consultation Service7311-60-009.pdf7311-60-00927-Jun-13
High Alert Medications - Identification, Double Check and Labeling7311-60-020.pdf7311-60-02017-Jul-13
Infant/Newborn Overnight When Mother/Primary Caregiver Admitted to Hospital7311-60-008.pdf7311-60-00805-May-16
Laser Safety7311-60-010.pdf7311-60-01025-Jun-14
Least Restraint - Mechanical and Environmental7311-60-012.pdf7311-60-01218-Jul-14
Medical Assistance in Dying7311-60-033.pdf7311-60-03308-Dec-16
Medical Directives7311-60-027.pdf7311-60-02719-May-16
Medical Marijuana7311-60-032.pdf7311-60-03205-May-16
Most Responsible Physician7311-60-002.pdf7311-60-00229-May-15
Ordering of Medications7311-60-004.pdf7311-60-00417-Jul-13
Organ and Tissue Donor Referral Policy7311-60-031.pdf7311-60-03129-Jun-13
Patient/Client Road Transportation Guidelines7311-60-006.pdf7311-60-00607-Oct-97
Release and Indemnification Policy7311-60-018.pdf7311-60-01830-Sep-10
Responding to Unwell/Injured Individuals on Hospital Grounds7311-60-025.pdf7311-60-02530-Sep-10
Resuscitation Policy7311-60-016.pdf7311-60-01615-Jun-15
Re-Use of Single Use Medical Devices7311-60-014.pdf7311-60-01401-Nov-04
Safe Labeling of Medications and Solutions on a Sterile Field7311-60-021.pdf7311-60-02122-Nov-07
Support for Breastfeeding 7311-60-022.pdf7311-60-02230-May-16
Surgical Safety Checklist7311-60-026.pdf7311-60-02622-Sep-16
Transfer, Lifting and Repositioning - Safe Moving and Client Handling7311-60-011.pdf7311-60-01105-Dec-11
Venous Thromboprophylaxis7311-60-030.pdf7311-60-03017-Jul-13
Verification of Identification7311-60-017.pdf7311-60-01729-Nov-13
Viewing and Release of Bodies7311-60-028.pdf7311-60-02829-Jun-12
collapse Category : 075 - Records and Reports ‎(13)
Abbreviations7311-75-006.pdf7311-75-00621-Feb-12
Access to Personal Health Information7311-75-002.pdf7311-75-00210-Feb-14
Amendment to Personal Health Information7311-75-008.pdf7311-75-00806-May-09
Disclosure of Personal Health Information to Police Services7311-75-009.pdf7311-75-00930-May-13
Documentation Standards - Health Records7311-75-007.pdf7311-75-00701-Jun-04
Documentation Standards - Health Records - Appendix A7311-75-007-Appendix-A.pdf7311-75-007-Appendix-A01-Jun-04
Facsimile (FAX)7311-75-011.pdf7311-75-01105-Dec-14
Facsmilie FAX - Appendix B7311-75-011-Appendix-B.pdf7311-75-011-Appendix-B05-Dec-14
Information Classification, Labelling and Handling7311-75-010.pdf7311-75-01009-Jun-15
Inter-Facility Transfer of Records - Acute Care7311-75-001.pdf7311-75-00105-Aug-97
Privacy and Confidentiality7311-75-003.pdf7311-75-00316-Mar-17
Retention of Personal Health Information7311-75-005.pdf7311-75-00510-Feb-01
Transfer of Information for Ongoing Care7311-75-004.pdf7311-75-00401-Apr-01
collapse Category : 080 - Emergency Preparedness ‎(1)
Business Continuity7311-80-001.pdf7311-80-00121-Feb-12
collapse Category : 095 - Facilities Services ‎(6)
Confined Space Management7311-95-006.pdf7311-95-00606-Dec-13
Fire Drill Policy7311-95-001.pdf7311-95-00101-Dec-16
Management of Surplus Assets 7311-95-002.pdf7311-95-00221-Feb-12
Medical Equipment – Management, Inspection, Maintenance and Repair7311-95-005.pdf7311-95-00526-Jul-13
SHR Parking Policy And Regulations7311-95-004.pdf7311-95-00424-Aug-12
Space Management Policy7311-95-003.pdf7311-95-00315-Apr-11
collapse Category : 100 - Research ‎(2)
Research7311-100-001.pdf7311-100-00123-Dec-14
Responsible Conduct of Research7311-100-002.pdf7311-100-00229-Nov-13
Last Modified: Tuesday, May 23, 2017 |
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