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Hospital circular letters - general

View general circular letters for hospitals. See links below for circular letters pertaining to more specific hospital services.
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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 

2023

DPH Memorandum, September 20, 2023: Sexual Assault Evidence Collection Kit Tracking System (TRACK-KIT®) (English, DOCX 49.94 KB)
Attachment A: Joint Commission Letter on Expired Sexual Assault Kits (English, DOCX 44.44 KB)
Attachment A: Joint Commission Letter on Expired Sexual Assault Kits (English, PDF 105.83 KB)
DPH Memorandum, April 2, 2023: Wayfinding, Signage, Lighting and Security Requirements for Hospitals with an Emergency Department (English, DOCX 46.17 KB)

2022

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

2020

Updated DPH Hospital “Code Black” Policy (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 (English, PDF 195.18 KB)

2016

#16-9-661 UPDATED Guidelines for Certification of Acuity Tools 9/30/2016 (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 (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 (English, DOC 102 KB)
#15-11-646 Identification and Referral of Veterans by Health Care Providers 11/10/2015 (English, DOCX 236.92 KB)
#15-10-643 Guidelines for Reporting Use of Electronic Health Records and Computerized 10/1/2015 (English, DOC 81.5 KB)
#15-10-642 Mass Casualty Patient Tracking Protocol 10/1/2015 (English, DOC 72 KB)
#15-9-641 Revocation and Suspension of Licensure based on Fraudulent Credentials (English, DOC 44.5 KB)
#15-06-636 Mass Casualty Patient Tracking Protocol for 2015 July 4th Celebrations 6/29/2015 (English, DOC 63 KB)
#15-03-632 Mass Casualty Patient Tracking Protocol for 119th Boston Marathon 3/27/2015 (English, DOC 57 KB)

2014

#14-07-619 Mass Casualty Patient Tracking Protocol for 2014 July 4th Celebrations 6/30/2014 (English, DOCX 34.98 KB)
#14-4-611 Mass Casualty Patient Tracking Protocol for 118th Boston Marathon 4/14/2014 (English, DOC 81.5 KB)

2013

#13-10-601 Revised Procedure for Reporting Blood Bank Activity 11/8/2013 (English, DOC 64 KB)
Technical Update to Circular Letter: DHCQ-13-10-602 11/19/2013 (English, DOC 35 KB)
#13-10-602 Guidelines for Reporting Use of Electronic Health Records and Computerized Provider Order Entry 10/31/2013 (English, DOC 45.5 KB)
#13-7-594 Guidelines for Reporting Mandatory Nurse Overtime 7/26/2013 (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 (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 (English, RTF 67 KB)

2012

Impact of Implementation of Mandatory Overtime Provisions of Chapter 224 
#12-12-579 Code Help Plans - 12/10/2012 (English, RTF 38 KB)
#12-8-564 Electronic Transmission of Correspondence (Non-Acute Hospitals) ListServ - 8/15/2012 (English, RTF 35.5 KB)
#12-4-561 Electronic Transmission of Correspondence ListServ - 6/7/2012 (English, RTF 42.5 KB)
#12-05-562 Clarification of Out-of-Hospital Dialysis Unit Regulations - 5/7/2012 (English, RTF 64 KB)

2011

DHCQ 11-01-545 - Care Transitions and Universal Transfer - 1/18/2011 (English, RTF 250.46 KB)
Universal Transfer Form and Instructions (English, RTF 25.4 MB)

2010

#10-11-540 Infection Prevention during Blood Glucose Monitoring and Insulin Administration - 11/24/2010 (English, RTF 58 KB)
#10-05-534 Changes in Procedures for Distributing Circular Letters - Request for Email Contact Information - 5/14/2010 (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 (English, RTF 50 KB)
Attachment A - waiver or modification of requirements (English, RTF 31 KB)
Attachment B - EMTALA Fact Sheet (English, RTF 171.5 KB)
Attachment C - Requesting an 1135 Waiver (English, RTF 47 KB)
Circular Letter: DHCQ 09-07-515 - Notification of Destruction of Medical Records (English, RTF 44 KB)
Records Destruction Fax Notification Form (English, RTF 157.82 KB)
#09-07-514 Patient and Family Advisory Councils - 7/8/2009 (English, RTF 274.52 KB)
#09-07-513 Boarding of Emergency Department (ED) Patients Awaiting a Bed - 7/8/200 (English, RTF 260.53 KB)
#09-01-504 Hospital Fire Safety and Evacuation Plans: Surges in Patient Volume/Boarding - 1/14/2009 (English, RTF 240.34 KB)
Memorandum to Heads of Fire Departments (English, DOC 81.5 KB)
Commissioner's Letter - RE: Hospital Emergency Department Crowding and Boarding (English, DOC 39 KB)

2008

#08-12-501 Discrete Substance Abuse Treatment Programs Operating under Hospital Licenses - 12/2/2008 (English, RTF 131.38 KB)
#08-09-499 Feasibility of Collecting Data on Restraint Use - 9/24/2008 (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 (English, RTF 151.19 KB)
CMS Memorandum S&C-06-33 (provided by CMS) 
Consent to Photograph Form (English, RTF 17.49 KB)
Survey Photo Log (English, RTF 70.83 KB)

2004

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

2001

#01-10-420 Governing the Discontinuance of Essential Health Services - 5/9/2001 (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 (English, RTF 47.47 KB)

1998

#5-98-381 Unlicensed Assistive Personnel - 5/1998 (English, RTF 40.43 KB)
Appropriate Use of of Unlicensed Assistive Personnel in Acute Care Institutions (English, RTF 14.93 KB)

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