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In this section
HCDOM Chapters
Chapter 1 – Health Care Governance and Administration
Chapter 2 – Patients’ Entitlements and Responsibilities
Chapter 3 – Health Care Operations
Chapter 4 – Special Circumstances
Chapter 5 – Administrative
Definitions
Resources
HCDOM Table of Contents
HCDOM to Web‑based Conversion Crosswalk
CCHCS Approved Abbreviations
How to Search the HCDOM
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Health Care Department Operations Manual
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Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
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Chapter 1 – Health Care Governance and Administration
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Article 1 – Statewide Health Care Governance
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1.1.1 Governing Body
1.1.2 Local Governing Body
Article 2 – Health Care Program Governance
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1.2.1 Complete Care Oversight Team Committee
1.2.2 Clinical Documentation and Decision Support Committee
1.2.3 Quality Management Program Overview
1.2.4 Quality Management Program, Statewide Governance
1.2.5 Quality Management Program, Institution
1.2.6 Statewide Patient Safety Program
1.2.7 Institution Patient Safety Program
1.2.10 Mortality Review and Reporting
1.2.11 CCHCS Systemwide Pharmacy and Therapeutics Committee
1.2.14 Medical Classification System
1.2.15 Utilization Management Program
1.2.16 Gender Affirming Surgery Review Committee
1.2.17 Continuing Health Care Education Planning Committee
1.2.18 Health Care Ethics Committee
1.2.19 Headquarters Durable Medical Equipment and Medical Supply Committee and Interdisciplinary Team
Article 3 – Health Care Workforce Governance
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1.3.2 Medical Peer Review Committee
1.3.4, Health Care Executive Committee
1.3.5 Behavioral Health Professional Peer Review Committee
Article 4.1 – Professional Workforce: Credentialing and Privileging
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1.4.1.1 Health Care Credentialing
1.4.1.2 Licensed Medical Provider Credentialing and Privileging
1.4.1.3 Behavioral Health Professional Credentialing Privileging
Article 4.2 – Professional Workforce: Medical Services
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1.4.2.1 New Medical Provider and Physician Manager Onboarding
1.4.2.2 Advanced Practice Provider
1.4.2.3 Medical Assistant
1.4.2.4 Medical Provider Documentation Expectations
1.4.2.5 Professional Practice Evaluation
Article 4.3 – Professional Workforce: Medical Peer Review Process
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1.4.3.1 For Cause Medical Peer Review
1.4.3.2 Medical Peer Review Referral and Intake
1.4.3.3 Safety Assessment, Summary and Automatic Privilege Modification
1.4.3.4 Informal Hearings
1.4.3.5 Peer Review Formal Investigation
1.4.3.6 Formal Appeal Judicial Review Committee
Article 4.4 – Professional Workforce: Allied Health Services
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1.4.4.1 Dietary Services Staff Onboarding and Competency Assessment
1.4.4.2 Laboratory Services Staff Onboarding and Competency Assessment
1.4.4.3 Medical Imaging Services Staff Onboarding and Competency Assessment
Article 4.5 – Professional Workforce: Pharmacy Services
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1.4.5.1 Pharmacy Staff Onboarding
1.4.5.2 Pharmacy Responsibilities, Scope of Service, and Supervision
1.4.5.3 Central Clinical Pharmacy Services
1.4.5.4 Impaired Pharmacy Personnel
Article 4.6 – Professional Workforce: Nursing Services
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1.4.6.1 Nursing Civil Service Staff Onboarding
1.4.6.2 Registry/Contracted Nursing Personnel Onboarding
1.4.6.3 Nursing Services Leadership
1.4.6.4 Nursing Professional Practice Model
1.4.6.5 Nursing Professional Practice Program
1.4.6.6 Professional Nursing Standards
1.4.6.7 Nursing Competency Program
1.4.6.8 Nursing Standardized Procedures, Protocols, Order Sets, Clinical Pathways, and Standing Orders
Chapter 2 – Patients’ Entitlements and Responsibilities
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Article 1 – Provision of Health Care Services
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2.1.1 Patients’ Rights
2.1.2 Effective Communication Documentation
2.1.3 Over‑the‑Counter Products
2.1.4 Reading Glasses
2.1.5 End of Life Option Act: Exemption
Article 2 – Confidentiality and Privacy
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2.2.1 General Use and Disclosure of Protected Health Information
2.2.2 Use and Disclosure of Protected Health Information Based on Patient Authorization
2.2.3 Sanctions and Penalties for Privacy and Information Security Violations
2.2.4 Minimum Necessary Use and Disclosure of Protected Health Information
2.2.5 Safeguards for Protected Health Information and Personally Identifiable Information
2.2.6 Use and Disclosure of Protected Health Information: Special Exceptions
2.2.7 Patient Privacy Rights
2.2.8 De‑Identification of Patient Information and Use of Limited Data Sets
2.2.9 Business Associate Use and Disclosure of Protected Health Information
2.2.10 General Use and Disclosure of Personally Identifiable Information
2.2.11 Privacy Incidents and Breach Reporting
2.2.13 Handling Protected Health and Personally Identifiable Information
2.2.14 Incidental Use and Disclosure of Protected Health Information
2.2.15 Specialized Government Functions
2.2.16 Health Oversight
2.2.17 Administrative Requirements for Privacy and Security Officials
2.2.18 Accounting of Disclosures for Patients’ Protected Health Information
Article 3 – Health Information Management
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2.3.1 Health Information Management Overview
2.3.2 Security and Privacy
2.3.3 Managing Health Record Access to Protected Health Information
2.3.4 Release of Protected Health Information
2.3.5 Health Information Exchange
2.3.6 Health Record Content and Organization
2.3.7 Health Record Viewing and Scanning
2.3.8 Health Record Documentation, Analysis, and Completion
2.3.9 Health Record Storage and Retrieval
2.3.10 Health Record Exception Process
2.3.11 Retention and Destruction
2.3.12 Death Records: Administrative Hold
2.3.13 Health Record Application/System Downtime Contingency Plan
2.3.15 Patient Health Care Inquiries
2.3.16 Patient’s Right to Amend Health Record
2.3.17 Disclosure of Protected Health Information for Public Health Activities
Article 4 – Health Care Directives
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2.4.1 Advance Directive for Health Care
2.4.2 Physician Orders for Life Sustaining Treatment (POLST)
Chapter 3 – Health Care Operations
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Article 1 – Complete Care Model
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3.1.1 Complete Care Model
3.1.2 Scope of Patient Care Services
3.1.3 Care Teams and Patient Panels
3.1.4 Patient Education
3.1.5 Scheduling and Access to Care
3.1.6 Population and Care Management Services
3.1.7 Care Management/Care Coordination
3.1.8 Reception Center
3.1.9 Health Care Transfer
3.1.10 Specialized Health Care Housing
3.1.11 Outpatient Specialty Services
3.1.13 Medical Imaging Services
3.1.14 Laboratory Services
3.1.15 Access to Contraceptive and Family Planning Services
3.1.16 Patient Care During Pregnancy and Childbirth
3.1.17 Palliative Care and Treatment
3.1.18 Registered Nurse Pronouncement of Death
3.1.19 Next of Kin Notification for Death, Serious Illness, or Serious Injury
3.1.20 Clinical Photography/Digital Imaging
3.1.21 Care Team Enhanced Conference
3.1.22 Compassionate Release
Article 2 – Health and Safety
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3.2.1 Disposal of Regulated Waste Generated by Health Care Staff
3.2.2 Aerosol Transmissible Diseases Control
3.2.3 Bloodborne Pathogens and Exposure Control
Article 3.1 – Dental Care: Preface
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3.3.1 Dental Care Definitions
3.3.1.1 Dental Care Introduction
3.3.1.2 The Standard of Medical Autonomy
Article 3.2 – Dental Care: Scope of Services
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3.3.2.1 Initial Health Screening – Receiving and Release
3.3.2.2 Dental Care – Reception Center
3.3.2.3 Comprehensive Dental Examinations – Mainline Facility
3.3.2.4 Periodontal Disease Program
3.3.2.5 Periodontal Disease Program for Pregnant Patients
3.3.2.6 Dental Prosthodontic Services
3.3.2.7 Dental Restorative Services
3.3.2.8 Oral Surgery
3.3.2.9 Endodontics
3.3.2.10 Fixed Prosthetics (Crown and Bridge)
3.3.2.11 Implants
3.3.2.12 Orthodontics
3.3.2.13 Facility Level Dental Health Orientation/Self Care
Article 3.3 – Dental Care: Health and Safety
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3.3.3.1 Infection Control Procedures
3.3.3.2 Control of Dental Instruments and Sharps
3.3.3.3 Dental Radiation Safety
3.3.3.4 Hazardous Material and Waste Management
Article 3.4 – Dental Care: Dental Clinic Administrative Procedures
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3.3.4.1 Dental Clinic Operations Reporting
3.3.4.2 Licensure and Credentialing
3.3.4.3 Dental Peer Review
3.3.4.4 Dental Program Subcommittee
3.3.4.5 Dental Authorization Review Committee
3.3.4.6 Dental Radiography
3.3.4.7 Clinic Space, Equipment and Supplies
3.3.4.8 Incarcerated Dental Workers
Article 3.5 – Dental Care: Dental Clinic Operations
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3.3.5.1 Priority Health Care Services Ducat Utilization
3.3.5.2 Recording and Scheduling Dental Encounters
3.3.5.3 Dental Priority Classification
3.3.5.4 Dental Treatment Plan
3.3.5.5 Interpreter Services
3.3.5.6 Patient’s Right to Refuse Treatment
3.3.5.7 Medical Emergencies in the Dental Clinic
3.3.5.8 Continuity of Care
3.3.5.9 Dental Emergencies
3.3.5.10 Direct Orders (Medical/Dental)
3.3.5.11 Supplemental Nutritional Support
3.3.5.12 Pharmaceuticals
3.3.5.13 Access to Dental Care
3.3.5.14 Dental Care
Article 3.6 – Dental Care: Health Services Record Management
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3.3.6.1 Health Records Organization and Maintenance
3.3.6.2 Informed Consent
3.3.6.3 Privacy of Care
3.3.6.4 Dental Chronos
3.3.6.5 Medical/Dental Lay‑Ins
3.3.6.6 Dental Holds and Patient Transport/Transfers
Article 3.7 – Dental Care: Abbreviations Index
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3.3.7 Abbreviations Used in Chapter 3, Article 3, Dental Care
Article 4 – Telehealth
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3.4.1 Telemedicine Specialty Services and Primary Care
Article 5 – Pharmacy and Medication Services
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3.5.1 Pharmacy and Medication Services
3.5.2 Pharmacy Licensing Requirements
3.5.3 Furnishing or Dispensing Medication to Legally Authorized Persons or Entities: Licensed Correctional Clinics
3.5.4 Automated Drug Delivery System
3.5.5 CCHCS Drug Formulary
3.5.6 Therapeutic Interchange and Automatic Substitution
3.5.7 Investigational Medications
3.5.8 Prescription/Order Requirements and Medication Availability
3.5.9 DEA Schedule II‑V Controlled Substances
3.5.10 CCHCS Pharmacy Policy and Procedure Review, Revisions, and Additions
3.5.11 Pharmacy Quality Assurance Program
3.5.12 High Alert Medications
3.5.13 Heat Alert Medications
3.5.14 Additional Requirements Pertaining to Licensed Inpatient Facilities
3.5.15 Procuring, Receiving, and Stocking of Medications
3.5.16 Medication Inventory Management, Labeling, and Storage
3.5.17 Handling of National Institute for Occupational Safety and Health (NIOSH) Hazardous Drugs
3.5.18 Repackaging and Compounding Medications
3.5.19 Medication Shortages or Backorders
3.5.20 Medication Continuity with Patient Movement: Transfer/Parole/Discharge/Re‑Entry Program
3.5.22 Emergency Drug Supplies
3.5.23 Medications Brought from a Non‑CDCR Facility
3.5.24 After‑Hours Pharmacy Services
3.5.25 Inspecting Medication Storage Areas
3.5.26 Break‑In, Theft/Loss from Pharmacy or Medication Storage Areas
3.5.27 Temporary Absence of the Pharmacist
3.5.28 Pharmacy Services Business Continuity Plan
3.5.29 Medication Administration
3.5.30 Medication Adherence
3.5.31 Handling of Confiscated Medications
3.5.32 340B Program
Article 6 – Durable Medical Equipment/Supplies and Accommodations
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3.6.1 Durable Medical Equipment and Medical Supply
3.6.2 Comprehensive Accommodation
Article 7 – Emergency Medical Response
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3.7.1 Emergency Medical Response System (Pre‑EMRP Go Live Institutions)
3.7.1‑1 Emergency Medical Response System (EMRP Go Live Institutions)
3.7.2 Emergency Medical Response Training Drill Nursing Skills Lab
3.7.3 Emergency Medical Response Bag Inventory/Audit
3.7.4 Emergency Medical Response: Post‑Event Review
3.7.5 Crash Cart Equipment
Article 8 – Public Health
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3.8.1 Public Health Disease Reporting
3.8.5 Coccidioidomycosis Waiver
3.8.6 Tuberculosis Program
3.8.7 Tuberculosis Surveillance Program
3.8.8 Communicating Precautions from Health Care Staff to Custody Staff
Article 9 – Dietary Services
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3.9.1 Dietary Interventions
Chapter 4 – Special Circumstances
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Article 1 – Health Care
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4.1.1 Hunger Strike and Food Refusal Event
4.1.2 Hygiene Intervention
4.1.3 Medical Evaluation for Assaults, Cell Extractions, and Use of Force
4.1.4 Foreign Body Examination
4.1.5 Contraband Surveillance Watch
4.1.6 Prison Rape Elimination Act
4.1.7 Gender Dysphoria Management
Chapter 5 – Administrative
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Article 1 – General Administration
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5.1.1 Implementation and Review of Health Care Regulations, Health Care Department Operations Manual, and Health Care Forms
5.1.2 California Public Records Act Requests
5.1.3 Medical Bed Management
5.1.4 Reporting of Actual or Suspected Incidents of Fraud, Errors, and Improper Governmental Activities
5.1.5 Disability Placement Program and Developmental Disability Program Staff Accountability
5.1.6 Non‑Paragraph 7 Process
5.1.7 Health Care Grievance
5.1.8 Compliance and Support Team
5.1.9 Protecting Employees from Retaliation
5.1.10 External Audits
Article 2 – Human Resources
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5.2.1 On‑Call/Standby and Callback
5.2.2 Nepotism and Fraternization Exception Request
5.2.3 Live Scan Fingerprinting
5.2.4 Administrative Time Off
5.2.5 Educational Rotation Program
5.2.6 Leave of Absence
5.2.7 Duty Statements and Organizational Charts
5.2.8 Bilingual Services
5.2.9 Exit Survey and Exit Interview
5.2.10 Merit Issue Complaints
5.2.11 Institutional Worker Supervision Pay
5.2.12 Lapse in Certification
5.2.13 Expired License, Certification, or Registration
5.2.14 Family and Medical Leave Act, California Family Rights Act, and Pregnancy Disability
Article 3 – Information Technology
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5.3.1 Lost and Stolen IT Assets
5.3.2 Camera Use
5.3.3 CCHCS‑Issued Mobile Phone
5.3.4 Digital Signature Security
5.3.5 Electronic Mail Retention
5.3.6 Information Security Policy Development and Maintenance
5.3.10 Change And Configuration Management
5.3.11 Endpoint Security
5.3.12 Security Analytics And Continuous Monitoring
5.3.13 Server Configuration
5.3.14 Access Control
5.3.15 Acceptable Use
5.3.16 Firewall Configuration
5.3.17 Physical and Environmental Protection
5.3.18 Security Assessment and Authorization
5.3.19 Audit and Accountability
5.3.20 Data Retention and Destruction
5.3.21 Data Security
5.3.22 eDiscovery and Litigation Hold
5.3.22.1 Health Care Litigation Support eDiscovery and Litigation Hold
5.3.23 Identification and Authentication
5.3.24 Incident Response
5.3.25 Security and Privacy Awareness Training
5.3.26 Software Management and Licensing
5.3.27 Generative Artificial Intelligence
Article 4 – Labor Relations
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5.4.1 Official Notice to Labor Organizations
Article 5 – Business Services
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5.5.1 Access to Leased Space
5.5.2 Building Security and Access
5.5.3 Staff Setup and Office Move Requests
5.5.4 Individual Workspace Reconfiguration
5.5.5 Requesting Standard Office Supplies
5.5.6 Conference and Quiet Rooms
5.5.7 Emergency Notification System Registration
5.5.8 Automated External Defibrillator
5.5.9 Cleaning and Disinfecting
5.5.10 Building Evacuation
5.5.11 Mail Center
5.5.12 Safe Mail Handling
5.5.13 Confidential Information Destruction
5.5.14 Digital Reprographics Services
5.5.15 Supplier Communication
5.5.16 Records Management Program
5.5.17 Prohibition on the Purchase of Promotional Items
5.5.18 Fleet Asset Acquisitions
5.5.19 Pooled Vehicle Reservations
5.5.20 Use of Privately Owned Vehicles and Rental Vehicles in the Conduct of State Business
5.5.21 Warehouse Operations
Article 6 – Contracts and Procurement
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5.6.1 Use of Federal Court Contracting Waiver
5.6.2 Prison Health Care Provider Network Web Portal Access and Provider Directory Usage
5.6.3 Registry Workforce Management System and Timekeeping
5.6.4 Working with Temporary/Relief Registry Providers
5.6.5 Pharmaceutical Acquisitions
5.6.6 Direct Health Care Service Contractor and/or Provider Performance Issue Reporting
Article 7 – Fiscal Management Section
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5.7.1 Payment of Non‑Contract Claims
5.7.2, Out‑of‑State Travel Requests
5.7.3, Staffing Allocations
Article 8 – Nursing Services
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5.8.1 Seniority Watch Preference for Supervising Registered Nurse II
5.8.2 Supervising Registered Nurse II Vacation or Annual Leave Requests
5.8.3 Supervising Registered Nurse II Overtime
Article 9 – Training
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5.9.1 General Training Requirements
5.9.2 Statewide Lean Six Sigma Program
Definitions
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Definitions
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Administrative Definitions
Health Care Definitions
