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MAP Policy Manual

Each MAP site registered with DPH must maintain a copy of this policy manual as part of the required reference materials for MAP certified staff.
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Policy Manual

Open PDF file, 1.36 MB,  MAP Policy Manual Final (English, PDF 1.36 MB)
Open DOCX file, 574.17 KB,  MAP Policy Manual Final (English, DOCX 574.17 KB)
Open DOCX file, 40.6 KB,  Guide to the MAP Policy Manual (English, DOCX 40.6 KB)
Open PDF file, 214.52 KB,  Guide to the MAP Policy Manual (English, PDF 214.52 KB)

Forms

Open DOCX file, 71.61 KB,  Section 02 Annual Observation of Medication Administration Form Sample 3-1-24 (English, DOCX 71.61 KB)
Open PDF file, 145.27 KB,  Section 02 Annual Observation of Medication Administration Form Sample 3-1-24 (English, PDF 145.27 KB)
Open DOCX file, 74.48 KB,  Section 05 MAP Recertification Competency Evaluation Form Required 11-17-25 (English, DOCX 74.48 KB)
Open PDF file, 172.1 KB,  Section 05 MAP Recertification Competency Evaluation Form Required 11-17-25 (English, PDF 172.1 KB)
Open DOCX file, 67.5 KB,  Section 05 MAP Recertification Evaluation Guide 11-17-25 (English, DOCX 67.5 KB)
Open PDF file, 126.64 KB,  Section 05 MAP Recertification Evaluation Guide 11-17-25 (English, PDF 126.64 KB)
Open DOCX file, 32.6 KB,  Section 08 Medication Reconciliation Discharge HCP Orders Checklist Sample (English, DOCX 32.6 KB)
Open PDF file, 67.53 KB,  Section 08 Medication Reconciliation Discharge HCP Orders Checklist Sample (English, PDF 67.53 KB)
Open DOCX file, 16.72 KB,  Section 10 OTC Dietary Supplement Without Pharm Label Training Template Sample (English, DOCX 16.72 KB)
Open PDF file, 180.1 KB,  Section 10 OTC Dietary Supplement Without Pharm Label Training Template Sample (English, PDF 180.1 KB)
Open DOCX file, 37.58 KB,  Section 15 Medication Disposal Record Form Required (English, DOCX 37.58 KB)
Open PDF file, 140.14 KB,  Section 15 Medication Disposal Record Form Required (English, PDF 140.14 KB)
Open DOCX file, 83.15 KB,  Section 17 Medication Occurrence Report Form (English, DOCX 83.15 KB)
Open PDF file, 264.28 KB,  Section 17 Medication Occurrence Report Form (English, PDF 264.28 KB)
Open DOCX file, 68.51 KB,  Section 18 Blood Glucose Monitoring Training Competency Form General Knowledge Optional (English, DOCX 68.51 KB)
Open PDF file, 207.33 KB,  Section 18 Blood Glucose Monitoring Training Competency Form General Knowledge Optional (English, PDF 207.33 KB)
Open DOCX file, 31.13 KB,  Section 18 Blood Glucose Monitoring Training Competency Form Individual Specific Optional (English, DOCX 31.13 KB)
Open PDF file, 143.54 KB,  Section 18 Blood Glucose Monitoring Training Competency Form Individual Specific Optional (English, PDF 143.54 KB)
Open DOCX file, 15.68 KB,  Section 18 Vital Signs Training Competency Eval Sample (English, DOCX 15.68 KB)
Open PDF file, 104.79 KB,  Section 18 Vital Signs Training Competency Eval Sample (English, PDF 104.79 KB)
Open PDF file, 166.25 KB,  Section 19 Clozapine Therapy Training Competency Eval-Required (English, PDF 166.25 KB)
Open DOCX file, 75.12 KB,  Section 19 Clozapine Therapy Training Competency Eval-Required (English, DOCX 75.12 KB)
Open DOCX file, 35.35 KB,  Section 19 Epinephrine via Auto Injector General Knowledge Required (English, DOCX 35.35 KB)
Open PDF file, 171 KB,  Section 19 Epinephrine via Auto Injector General Knowledge Required (English, PDF 171 KB)
Open DOCX file, 32.89 KB,  Section 19 Epinephrine via Auto Injector Individual Specific Required (English, DOCX 32.89 KB)
Open PDF file, 158.26 KB,  Section 19 Epinephrine via Auto Injector Individual Specific Required (English, PDF 158.26 KB)
Open DOCX file, 21.49 KB,  Section 19 Epinephrine via Auto Injector Return Demonstration Required (English, DOCX 21.49 KB)
Open PDF file, 187.44 KB,  Section 19 Epinephrine via Auto Injector Return Demonstration Required (English, PDF 187.44 KB)
Open DOCX file, 71.44 KB,  Section 19 G-J Tube Competency Eval Completion of Feeding Return Demonstration Optional (English, DOCX 71.44 KB)
Open PDF file, 191.2 KB,  Section 19 G-J Tube Competency Eval Completion of Feeding Return Demonstration Optional (English, PDF 191.2 KB)
Open DOCX file, 71.27 KB,  Section 19 G-J Tube Competency Eval Bolus Feeding Return Demonstration Optional (English, DOCX 71.27 KB)
Open PDF file, 190.26 KB,  Section 19 G-J Tube Competency Eval Bolus Feeding Return Demonstration Optional (English, PDF 190.26 KB)
Open DOCX file, 72.17 KB,  Section 19 G-J Tube Competency Eval Continuous Feeding Return Demonstration Optional (English, DOCX 72.17 KB)
Open PDF file, 193.79 KB,  Section 19 G-J Tube Competency Eval Continuous Feeding Return Demonstration Optional (English, PDF 193.79 KB)
Open DOCX file, 19.65 KB,  Section 19 G-J Tube Competency Eval Medication Administration Return Demonstration Required (English, DOCX 19.65 KB)
Open PDF file, 141.7 KB,  Section 19 G-J Tube Competency Eval Medication Administration Return Demonstration Required (English, PDF 141.7 KB)
Open DOCX file, 22.33 KB,  Section 19 G-J Tube Competency Eval Water Flush Return Demonstration Required (English, DOCX 22.33 KB)
Open PDF file, 136.12 KB,  Section 19 G-J Tube Competency Eval Water Flush Return Demonstration Required (English, PDF 136.12 KB)
Open DOCX file, 12.07 KB,  Section 19 G-J Tube Management Form Required (English, DOCX 12.07 KB)
Open PDF file, 166.96 KB,  Section 19 G-J Tube Management Form Required (English, PDF 166.96 KB)
Open DOCX file, 74.46 KB,  Section 19 G-J Tube Medication Administration General Knowledge Competency Eval Required (English, DOCX 74.46 KB)
Open PDF file, 241.42 KB,  Section 19 G-J Tube Medication Administration General Knowledge Competency Eval Required (English, PDF 241.42 KB)
Open DOCX file, 74.87 KB,  Section 19 G-J Tube Medication Administration Individual Specific Competency Eval Required (English, DOCX 74.87 KB)
Open PDF file, 199.79 KB,  Section 19 G-J Tube Medication Administration Individual Specific Competency Eval Required (English, PDF 199.79 KB)
Open DOCX file, 38.18 KB,  Section 19 Insulin Administration via Insulin Pen by MAP Certified Staff Training Competency Evaluation Tool for General Knowledge (English, DOCX 38.18 KB)
Open PDF file, 196.24 KB,  Section 19 Insulin Administration via Insulin Pen by MAP Certified Staff Training Competency Evaluation Tool for General Knowledge (English, PDF 196.24 KB)
Open DOCX file, 40.84 KB,  Insulin Administration via Insulin Pen by MAP Certified Staff Training Competency Evaluation Tool for ‘Individual-Specific’ (English, DOCX 40.84 KB)
Open PDF file, 205.99 KB,  Insulin Administration via Insulin Pen by MAP Certified Staff Training Competency Evaluation Tool for ‘Individual-Specific’ (English, PDF 205.99 KB)
Open DOCX file, 35.71 KB,  Section 19 Insulin Administration via Insulin Pen by MAP Certified Staff Training Return-Demonstration Competency Evaluation Tool for ‘Initial’ (English, DOCX 35.71 KB)
Open PDF file, 199.89 KB,  Section 19 Insulin Administration via Insulin Pen by MAP Certified Staff Training Return-Demonstration Competency Evaluation Tool for ‘Initial’ (English, PDF 199.89 KB)
Open DOCX file, 35.54 KB,  Section 19 Insulin Administration via Insulin Pen by MAP Certified Staff Training and Demonstration Competency Evaluation Tool (English, DOCX 35.54 KB)
Open PDF file, 197.91 KB,  Section 19 Insulin Administration via Insulin Pen by MAP Certified Staff Training and Demonstration Competency Evaluation Tool (English, PDF 197.91 KB)
Open DOCX file, 19.24 KB,  Section 19 HCP Orders Telephone Telehealth Warfarin Sodium Optional (English, DOCX 19.24 KB)
Open PDF file, 186.53 KB,  Section 19 HCP Orders Telephone Telehealth Warfarin Sodium Optional (English, PDF 186.53 KB)
Open DOCX file, 9.73 KB,  Section 19 HCP Orders Warfarin Sodium Optional (English, DOCX 9.73 KB)
Open PDF file, 133.51 KB,  Section 19 HCP Orders Warfarin Sodium Optional (English, PDF 133.51 KB)
Open DOCX file, 24.69 KB,  Section 19 Narrative Notes Optional (English, DOCX 24.69 KB)
Open PDF file, 189.58 KB,  Section 19 Narrative Notes Optional (English, PDF 189.58 KB)
Open DOCX file, 66.16 KB,  Section 19 Oxygen Therapy Protocol Optional (English, DOCX 66.16 KB)
Open PDF file, 156.43 KB,  Section 19 Oxygen Therapy Protocol Optional (English, PDF 156.43 KB)
Open DOCX file, 71.1 KB,  Section 19 Oxygen Therapy Training General Knowledge Competency Eval Optional (English, DOCX 71.1 KB)
Open PDF file, 186.2 KB,  Section 19 Oxygen Therapy Training General Knowledge Competency Eval Optional (English, PDF 186.2 KB)
Open DOCX file, 30.83 KB,  Section 19 Oxygen Therapy Training Individual Specific Competency Eval Optional (English, DOCX 30.83 KB)
Open PDF file, 148.2 KB,  Section 19 Oxygen Therapy Training Individual Specific Competency Eval Optional (English, PDF 148.2 KB)
Open DOCX file, 66.16 KB,  Section 19 Warfarin Sodium Chronological Event Sheet Optional (English, DOCX 66.16 KB)
Open PDF file, 160.91 KB,  Section 19 Warfarin Sodium Chronological Event Sheet Optional (English, PDF 160.91 KB)
Open DOCX file, 34.08 KB,  Section 19 Warfarin Sodium Competency Eval Tool General Knowledge Required (English, DOCX 34.08 KB)
Open PDF file, 186.49 KB,  Section 19 Warfarin Sodium Competency Eval Tool General Knowledge Required (English, PDF 186.49 KB)
Open DOCX file, 32.96 KB,  Section 19 Warfarin Sodium Competency Eval Tool Individual Specific Warfarin Required (English, DOCX 32.96 KB)
Open PDF file, 159.42 KB,  Section 19 Warfarin Sodium Competency Eval Tool Individual Specific Warfarin Required (English, PDF 159.42 KB)
Open PDF file, 155.76 KB,  Section 19 Warfarin Sodium Medication Sheet Alternating Doses Sample (English, PDF 155.76 KB)
Open DOCX file, 24.31 KB,  Section 19 Warfarin Sodium Medication Sheet Alternating Doses Sample (English, DOCX 24.31 KB)
Open DOCX file, 22.5 KB,  Section 19 Warfarin Sodium Medication Sheet Sample (English, DOCX 22.5 KB)
Open PDF file, 166.95 KB,  Section 19 Warfarin Sodium Medication Sheet Sample (English, PDF 166.95 KB)
Open DOCX file, 11.07 KB,  Section 19 Warfarin Sodium Therapy Protocol Sample (English, DOCX 11.07 KB)
Open PDF file, 135.93 KB,  Section 19 Warfarin Sodium Therapy Protocol Sample (English, PDF 135.93 KB)
Open DOCX file, 80.55 KB,  Section 20 Learning to Self-Administer Medication Teaching Support Plan Sample (English, DOCX 80.55 KB)
Open PDF file, 206.67 KB,  Section 20 Learning to Self-Administer Medication Teaching Support Plan Sample (English, PDF 206.67 KB)
Open DOCX file, 77.76 KB,  Section 20 Observation Tool for Self-Medication Administration Skills Sample (English, DOCX 77.76 KB)
Open PDF file, 242.9 KB,  Section 20 Observation Tool for Self-Medication Administration Skills Sample (English, PDF 242.9 KB)
Open DOCX file, 66.23 KB,  Section 22 Hospice Admission to Hospices Services Care Checklist Sample (English, DOCX 66.23 KB)
Open PDF file, 132.15 KB,  Section 22 Hospice Admission to Hospices Services Care Checklist Sample (English, PDF 132.15 KB)
Open DOCX file, 64.85 KB,  Section 22 Hospice Contacts List Sample (English, DOCX 64.85 KB)
Open PDF file, 93.67 KB,  Section 22 Hospice Contacts List Sample (English, PDF 93.67 KB)
Open DOCX file, 80.75 KB,  Section 22 Hospice Intake Addendum Form Sample (English, DOCX 80.75 KB)
Open PDF file, 256.8 KB,  Section 22 Hospice Intake Addendum Form Sample (English, PDF 256.8 KB)
Open DOCX file, 62.65 KB,  Section 22 Hospice Notebook Cover Sheet Optional (English, DOCX 62.65 KB)
Open PDF file, 176.54 KB,  Section 22 Hospice Notebook Cover Sheet Optional (English, PDF 176.54 KB)
Open DOCX file, 63.91 KB,  Section 22 Hospice Notebook Tabs Optional (English, DOCX 63.91 KB)
Open PDF file, 127.98 KB,  Section 22 Hospice Notebook Tabs Optional (English, PDF 127.98 KB)
Open DOCX file, 74.05 KB,  Section 22 Hospice Pain Review for Non-Verbal Individual Form Sample (English, DOCX 74.05 KB)
Open PDF file, 201.98 KB,  Section 22 Hospice Pain Review for Non-Verbal Individual Form Sample (English, PDF 201.98 KB)
Open DOCX file, 67.66 KB,  Section 22 Hospice Progress Narrative Notes Sample (English, DOCX 67.66 KB)
Open PDF file, 119.14 KB,  Section 22 Hospice Progress Narrative Notes Sample (English, PDF 119.14 KB)

MAP Advisories and Resources

MAP Advisories and Resources 

Archived MAP Policy

Open PDF file, 3.07 MB,  MAP Policy Manual - 4.15.25 (PDF) (English, PDF 3.07 MB)
Open DOCX file, 623.5 KB,  MAP Policy Manual - 4.15.25 (DOCX) (English, DOCX 623.5 KB)
Open PDF file, 4.74 MB,  MAP Policy Manual - 12.2.24 (PDF) (English, PDF 4.74 MB)
Open DOCX file, 629.66 KB,  MAP Policy Manual - 12.2.24 (DOCX) (English, DOCX 629.66 KB)
Open PDF file, 2.16 MB,  MAP Policy Manual – 11.15.2023 (PDF) (English, PDF 2.16 MB)
Open DOCX file, 706.27 KB,  MAP Policy Manual – 11.15.2023 (DOCX) (English, DOCX 706.27 KB)
Open PDF file, 2.7 MB,  MAP Policy Manual - 6.28.2023 (PDF) (English, PDF 2.7 MB)
Open DOCX file, 1.04 MB,  MAP Policy Manual - 6.28.2023 (DOCX) (English, DOCX 1.04 MB)
Open PDF file, 2.01 MB,  MAP Policy Manual - 2015 (PDF) (English, PDF 2.01 MB)
Open DOCX file, 723.07 KB,  MAP Policy Manual - 2015 (DOCX) (English, DOCX 723.07 KB)

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