Hospital circular letters - general

Circular letters for other hospital services

Emergency Department

Healthcare Associated Infections

Invasive Cardiovascular Services

Mammography Services

Maternal and Newborn Services

Medical Control Service

MOLST (Medical Orders for Life-Sustaining Treatment)

Reporting Serious Incidents

Seasonal Influenza Vaccination of Healthcare Personnel

Sexual and Domestic Violence

Stroke Services

Trauma Centers

2026

DPH Memorandum, September 11, 2026: Addressing Delays in Patients Receiving the Appropriate Level and Site of Perinatal Care, When Transfer is Necessary, Open DOCX file, 45.25 KB (English, DOCX 45.25 KB)

DPH Memorandum, May 27, 2026: Mass Casualty Patient Tracking Protocol, Open DOCX file, 81.82 KB (English, DOCX 81.82 KB)

2025

DPH Memo, August 18, 2025: Updated Regulatory Requirements for Licensed Hospitals and Licensed Clinics Providing Birth Center Services, Open DOCX file, 42.86 KB (English, DOCX 42.86 KB)

DPH Memorandum, March 10, 2025: Process for Adding Beds in Alternate Inpatient Beds, Open PDF file, 263.05 KB (English, PDF 263.05 KB)

DPH Memorandum, March 10, 2025: Process for Adding Beds in Alternate Inpatient Beds, Open DOCX file, 61.73 KB (English, DOCX 61.73 KB)

2024

Updated Hospital Capacity Data Reporting Requirements, Open DOCX file, 54.33 KB (English, DOCX 54.33 KB)

Appendix A – Data Elements, Open DOCX file, 40.49 KB (English, DOCX 40.49 KB)

2023

DPH Memorandum, September 20, 2023: Sexual Assault Evidence Collection Kit Tracking System (TRACK-KIT®), Open DOCX file, 49.94 KB (English, DOCX 49.94 KB)

Attachment A: Joint Commission Letter on Expired Sexual Assault Kits, Open DOCX file, 44.44 KB (English, DOCX 44.44 KB)

Attachment A: Joint Commission Letter on Expired Sexual Assault Kits, Open PDF file, 105.83 KB (English, PDF 105.83 KB)

DPH Memorandum, April 2, 2023: Wayfinding, Signage, Lighting and Security Requirements for Hospitals with an Emergency Department, Open DOCX file, 46.17 KB (English, DOCX 46.17 KB)

2022

DPH Memorandum, October 31, 2022: Management of Pediatric Respiratory Illness Patients during times of Capacity Constraints, Open DOCX file, 34.56 KB (English, DOCX 34.56 KB)

2020

Updated DPH Hospital “Code Black” Policy, Open DOCX file, 44.58 KB (English, DOCX 44.58 KB)

2019

Memo: Tuberculosis Screening, Testing and Treatment of Healthcare Personnel – November 2019

Ongoing Intravenous Immune Globulin (IVIG) shortages

2017

Circular Letter: DHCQ 17-1-668 Implementation of the STEP Law: Voluntary Non-Opioid Directive Form – 1/24/2017 - English, Open PDF file, 195.18 KB (English, PDF 195.18 KB)

2016

#16-9-661 UPDATED Guidelines for Certification of Acuity Tools 9/30/2016, Open DOCX file, 48.93 KB (English, DOCX 48.93 KB)

#16-4-658 Reporting of Newborn Substance Exposure and Hospitalizations Caused by Ingestion of a Controlled Substance 04/14/2016, Open DOCX file, 51.64 KB (English, DOCX 51.64 KB)

2015

#15-11-647 Guidelines for Certification of Acuity Tools pursuant to 958 CMR 8.00, "Patient Assignment Limits for Registered Nurses in Intensive Care Units in Acute Hospitals" 11/24/2015, Open DOC file, 102 KB (English, DOC 102 KB)

#15-11-646 Identification and Referral of Veterans by Health Care Providers 11/10/2015, Open DOCX file, 236.92 KB (English, DOCX 236.92 KB)

#15-10-643 Guidelines for Reporting Use of Electronic Health Records and Computerized 10/1/2015 , Open DOC file, 81.5 KB (English, DOC 81.5 KB)

#15-9-641 Revocation and Suspension of Licensure based on Fraudulent Credentials, Open DOC file, 44.5 KB (English, DOC 44.5 KB)

2013

#13-10-601 Revised Procedure for Reporting Blood Bank Activity 11/8/2013, Open DOC file, 64 KB (English, DOC 64 KB)

Technical Update to Circular Letter: DHCQ-13-10-602 11/19/2013, Open DOC file, 35 KB (English, DOC 35 KB)

#13-10-602 Guidelines for Reporting Use of Electronic Health Records and Computerized Provider Order Entry 10/31/2013, Open DOC file, 45.5 KB (English, DOC 45.5 KB)

#13-7-594 Guidelines for Reporting Mandatory Nurse Overtime 7/26/2013, Open DOC file, 91.5 KB (English, DOC 91.5 KB)

#13-04-588 Transition to web-based reporting of incidents using the Health Care Facility Reporting System (HCFRS) - 04/22/2013, Open RTF file, 399.04 KB (English, RTF 399.04 KB)

#13-01-583 Reducing the Need for Boarding of Patients and Authorization and Guidelines for Use of Alternate Space for Patients Presenting with Influenza-like Illness (ILI) - 1/14/2013, Open RTF file, 67 KB (English, RTF 67 KB)

2012

Impact of Implementation of Mandatory Overtime Provisions of Chapter 224

#12-12-579 Code Help Plans - 12/10/2012, Open RTF file, 38 KB (English, RTF 38 KB)

#12-8-564 Electronic Transmission of Correspondence (Non-Acute Hospitals) ListServ - 8/15/2012, Open RTF file, 35.5 KB (English, RTF 35.5 KB)

#12-4-561 Electronic Transmission of Correspondence ListServ - 6/7/2012, Open RTF file, 42.5 KB (English, RTF 42.5 KB)

#12-05-562 Clarification of Out-of-Hospital Dialysis Unit Regulations - 5/7/2012, Open RTF file, 64 KB (English, RTF 64 KB)

2011

DHCQ 11-01-545 - Care Transitions and Universal Transfer - 1/18/2011, Open RTF file, 250.46 KB (English, RTF 250.46 KB)

Universal Transfer Form and Instructions, Open RTF file, 25.4 MB (English, RTF 25.4 MB)

2010

#10-11-540 Infection Prevention during Blood Glucose Monitoring and Insulin Administration - 11/24/2010, Open RTF file, 58 KB (English, RTF 58 KB)

#10-05-534 Changes in Procedures for Distributing Circular Letters - Request for Email Contact Information - 5/14/2010, Open RTF file, 41.5 KB (English, RTF 41.5 KB)

2009

#09-11-524 Waiver or Modification of Federal Requirements Under Section 1135 of the Social Security Act - 11/3/2009, Open RTF file, 50 KB (English, RTF 50 KB)

Attachment A - waiver or modification of requirements, Open RTF file, 31 KB (English, RTF 31 KB)

Attachment B - EMTALA Fact Sheet, Open RTF file, 171.5 KB (English, RTF 171.5 KB)

Attachment C - Requesting an 1135 Waiver, Open RTF file, 47 KB (English, RTF 47 KB)

Circular Letter: DHCQ 09-07-515 - Notification of Destruction of Medical Records, Open RTF file, 44 KB (English, RTF 44 KB)

Records Destruction Fax Notification Form, Open RTF file, 157.82 KB (English, RTF 157.82 KB)

#09-07-514 Patient and Family Advisory Councils - 7/8/2009, Open RTF file, 274.52 KB (English, RTF 274.52 KB)

#09-07-513 Boarding of Emergency Department (ED) Patients Awaiting a Bed - 7/8/200, Open RTF file, 260.53 KB (English, RTF 260.53 KB)

#09-01-504 Hospital Fire Safety and Evacuation Plans: Surges in Patient Volume/Boarding - 1/14/2009, Open RTF file, 240.34 KB (English, RTF 240.34 KB)

Memorandum to Heads of Fire Departments, Open DOC file, 81.5 KB (English, DOC 81.5 KB)

Commissioner's Letter - RE: Hospital Emergency Department Crowding and Boarding, Open DOC file, 39 KB (English, DOC 39 KB)

2008

#08-12-501 Discrete Substance Abuse Treatment Programs Operating under Hospital Licenses - 12/2/2008, Open RTF file, 131.38 KB (English, RTF 131.38 KB)

#08-09-499 Feasibility of Collecting Data on Restraint Use - 9/24/2008, Open RTF file, 251.41 KB (English, RTF 251.41 KB)

#08-07-495 - Forced Removal of Clothing of Patients in Hospital Emergency Departments

#08-03-484 Use of Cameras During the Survey Process - 3/25/2008, Open RTF file, 151.19 KB (English, RTF 151.19 KB)

CMS Memorandum S&C-06-33 (provided by CMS) (PDF)

Consent to Photograph Form, Open RTF file, 17.49 KB (English, RTF 17.49 KB)

Survey Photo Log, Open RTF file, 70.83 KB (English, RTF 70.83 KB)

2004

#04-6-442 New Consent Requirements for Autopsy - 6/2004, Open RTF file, 28.45 KB (English, RTF 28.45 KB)

2001

#01-10-420 Governing the Discontinuance of Essential Health Services - 5/9/2001, Open RTF file, 62.46 KB (English, RTF 62.46 KB)

#01-01-409 Temporary Placement of Medical/Surgical Patients into TCU Beds/Relicensure of Previously Licensed Space - 1/19/2001, Open RTF file, 47.47 KB (English, RTF 47.47 KB)

1998

#5-98-381 Unlicensed Assistive Personnel - 5/1998, Open RTF file, 40.43 KB (English, RTF 40.43 KB)

Appropriate Use of of Unlicensed Assistive Personnel in Acute Care Institutions, Open RTF file, 14.93 KB (English, RTF 14.93 KB)