Welcome to Loyola. We trust that you will have a positive clinical experience at Loyola
and wish you a successful semester!
CLINICAL AT LOYOLA UNIVERSITY
HEALTH SYSTEM (LUHS)
Information for the
Student, Instructor and School of Nursing
(SON)
Please review all content pertinent to your position (i.e. student, instructor, or SON). All
documents and forms are contained herein unless otherwise noted.
Contacts:
 LUHS Department of Nursing Education Clinical Coordinator Ann-Marie Burke:
(aburke@lumc.edu) (708) 216-3477

LUHS Computer HELP Desk: (708)216-2160 (for difficulty with log-on, forgotten passwords or
Lawson numbers)

EPIC Trainer: Bindiya Shah( bshah@lumc.edu) 708-216-3932
Updated Information:
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QuantiFERON TB Gold or T-SPOT T.B. test- p. 8
New Trinity Confidentiality Agreement- p. 7 & 46-48
Patient Huddles- p. 25
Patient Identification and Critical tasks- p. 30
Health Stream Access Guidelines- p. 20
Bedside Point of Care Medication Administration- p. 38-39
Page 1 of 48
Updated 12/12/2014
LUHS Clinical Forms – Appendix section of this document
Clinical at Loyola University Health System (LUHS)
Information for the Student, Instructor and School of Nursing (SON)
Table of Content and Appendix Listing
Pages
Section and Sample of Topics
Audience
Section 2
4-7
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SON
Contracts & Certificates of Insurance
Inquiries and Paperwork
Scheduling Clinical
Preceptor clinical
Form A – Loyola Clinical Request
Form B – Loyola Clinical Rotation Information
Confidentiality Statements
Section 3
8-10
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Orientation Checklist – Student and Instructor
Clinical Areas with Requirements Unique to the Setting
Units Used for Clinical Group Placement
Student, Instructor
and SON
Section 4
11-16
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New Instructors at Loyola
New Instructor Shadowing Experience
Prior to Starting Clinical
First Day of Clinical
Clinical Time
Clinical Group Size
Arrangements for Clinical Meeting/Conference Rooms
End of Clinical Term (Survey)
Clinical Instructor Role in the Supervision of Students at
LUHS
Forms for Use on the Clinical Unit
o Student Skills List
o Student Nurse Patient Assignment Sheet
Instructor
Section 5
17-24
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Skills Student Nurses can NOT perform at Loyola
Observational Experiences
Potential areas for Observation (Critical Care & Other)
Orientation Requirements
Instructor/Student that is ALSO an Employee of LUHS
Additional Training Requirements
E-learning Orientation Requirements
E-Learning Instructions HealthStream and EPIC
Page 2 of 48
Student and
Instructor
Updated 12/12/2014
Pages
Section and Sample of Topics
Audience
Section 6
25-36
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Student and
Instructor
Purposeful Hourly Rounding
MAGIS
LUHS Nursing Professional Practice Model
Joint Commission Preparedness
Medication Administration
Overview / Guidelines / Policy
o Cell Phones and Other Wireless Devices
o Computer Access, Omni Cell or Pyxis Help
o Computers / Telephones / Nursing Station
o Dress Code
o Drug-Free Workplace
o HIPPA/General Compliance Violations
o ID Badges
o Injury on the Job
o Parking
o Respectful Workplace
o Sexual Harassment
o Smoking
o Solicitation or distribution of Literature or Goods
Resources Available
o Patient care Policy & Procedure
o Medical References
o Library
Appendix Listing
Document Title
Appendix Page
Medication Scanning
Health Science Campus Map
EPIC Quick Reference
Student Nurse Patient Assignment Sheet
Nursing Student Skills Check List
Orientation Checklist – Student & Instructor
Confidentiality Statement
Page 3 of 48
Student, Instructor
Student. Instructor
Student. Instructor
Instructor
SON, Instructor
Instructor , Student
Instructor, Student
Updated 12/12/2014
38-39
40
41-42
43
44
45
46-48
Section 2 – Information for the SON
Contracts and Certificates of Insurance
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Prior to consideration of clinical placement, a contract between the School of Nursing (SON) and
Loyola University Health System for Nursing Student clinical must be in place.
New contracts or questions about Nursing School contracts are to be referred to the Manager of
Nursing Education.
Certificates of Insurance are to be directed to the Manager of Nursing Education at
PCLEME1@lumc.edu.
School of Nursing Clinical Inquiries and Paperwork


School of Nursing inquiries and paper work, other than contracts or certificates of insurance, are to
be submitted to the SON Coordinator in the Department of Nursing Education.
Forms submitted are to be the current version.
Guidelines for Scheduling a Clinical Experience
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The SON must have a contract with Loyola for the Nursing Student clinical.
Clinical time must be 32 hours or more to be considered.
Observational clinical experiences are NOT considered.
Except for Preceptor experiences, clinical is NOT scheduled in ICU settings.
Requests for placement are submitted via Form “A”- Loyola Clinical Request.
Loyola students are placed before other Schools are considered.
Placement is NOT guaranteed until the SON receives written notice “Confirmation of Clinical”
from Loyola.
Page 4 of 48
Updated 12/12/2014
Section 2 – Information for the SON
Preceptor Clinical Experiences
Form “A”- Loyola Clinical Request

Da te of Reques t(s ):
Clinical Request Guide:
-S
hif
ts
es
pp
St r ox
ud #
en
ts
A
Tim
D
ay
(s
)
re of
qu W
es ee
te k
d
(1) Form A i s us ed by School s of Nurs i ng (SON) to s ubmi t reques ts for s tudent nurs e cl i ni ca l experi ences a t Loyol a .
(2) Form A s houl d be s ubmi tted a t l ea s t 3 months before s ta rt of s emes ter vi a e-ma i l to pa fa l k@l umc.edu
(3) LUHS s ends Confi rma ti on of Cl i ni ca l Approva l a t l ea s t 2 months pri or to cl i ni ca l s emes ter to SON; unl es s form A wa s s ubmi tted l a te to LUMC.
(4) SON compl etes a Form B - Loyol a Cl i ni ca l Rota ti on Informa ti on form provi di ng i ns tructor/s tudent i nforma ti on a nd s ubmi ts i t to LUMC a t l ea s t four (4)
weeks pri or to the cl i ni ca l s ta rt da te.
(5) LUHS proces s es the s ubmi tted Form B. The proces s ed Form B i s returned to the SON. The SON provi des tra i ni ng a nd confi denti a l a cces s i nforma ti on
provi ded wi th the Form B to the SON. The SON i s to provi de i nforma ti on to fa cul ty a nd s tudents a s a ppropri a te.
(6) At the end of cl i ni ca l , i t i s the expecta ti on tha t i ns tructor & s tudents compl ete a n on-l i ne Ins tructor/Student Cl i ni ca l Eva l ua ti on Form.
U
n
re it(s
qu )
es
te
d

FORM "A" Loyola Clinical Request
School Name:
Na me of Conta ct Pers on for the Reques t:
ou
rs
e#
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Arrangements for clinical assignment are made through
the Department of Nursing Education and the SON.
Form “A” is used to request clinical placement.
Placement request information must be accurate as
determination of placement is based on this
information.
Request can be submitted months in advance of the
clinical term
The Clinical Coordinator will not make a determination
of placement until Loyola placement requests for the
specified term are processed.
C

FORM A – Loyola Clinical Request
La
st
D Cli
ay n
O ica
n-S l
D ite
at
e

lin
ic
a
n- l D
Sit ay
ay e
/D
at
e

O

D
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1s
tC

ou
rs
ap e ID
pli ,
ca if
ble

Available only to senior BSN students at the end of their final clinical term.
Arrangements for preceptor experiences are made between the SON and the Department of Nursing
Education. Instructors/students should NOT contact unit/department managers to arrange for a
preceptor clinical experience.
The school must provide the name and contact information for the Illinois licensed MSN prepared
faculty responsible for student oversight and evaluation of the clinical experience.
Schools of Nursing outside of Illinois must get approval from the State Board of Nursing. Loyola does
not send resumes or nursing licenses of its employees to the State of Illinois for this purpose. [See
Illinois Nurse Practice Act Joint Committee Administrative Rules section 1300.340 approval of
programs out of state Education Programs seeking student nurse clinical placement in Illinois.] .
Students are assigned a RN preceptor and follow the preceptor’s schedule
Student placements are limited by the number of preceptors assigned to the role by the unit/area
manager.
During the time when Loyola students are scheduled with preceptors, other Schools will not be
scheduled. Loyola students are scheduled during the following periods:
st
o Mid-March to May 1
o Mid-October to mid-December
The school of nursing is responsible to provide the preceptor/unit manager with student objectives
and/or expectations. Skill performance requires that the student has the educational foundation to
perform safely under the supervision of the preceptor.
For SON using a RN Preceptor, a formal “thank you” to the preceptor is appropriate. RN preceptors
with national certification require a letter to validate the preceptor role; for such cases, the SON may
either write their own letter or obtain the ANCC Certification Record at the ANCC web site:
o http://www.nursecredentialing.org/RenewCertification.aspx and, once there, click on the on the
picture of the ANCC Certification Record
C


Reques t 1
Dates OFF (holdiay, breaks):
Comment:
Reques t 2
Dates OFF (holdiay, breaks):
Comment:
Request 3
Dates OFF (holdiay, breaks):
Comment:
Request 4
Dates OFF (holdiay, breaks):
Comment:
Request 5
Dates OFF (holdiay, breaks):
Comment:
Request 6
“FORM A” IS NOT CONTAINED IN THIS GUIDE
Dates OFF (holdiay, breaks):
Comment:
Request 7
Dates OFF (holdiay, breaks):
Comment:
Request 8
Dates OFF (holdiay, breaks):
Comment:
Reques t 9
Dates OFF (holdiay, breaks):
Comment:
Request 10
Dates OFF (holdiay, breaks):
Comment:
Request 11
Dates OFF (holdiay, breaks):
Comment:
Request 12
Dates OFF (holdiay, breaks):
Comment:
Page 5 of 48
Updated 12/12/2014
Section 2 – Information for the SON
Clinical Confirmation
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Upon receipt of confirmation, the SON checks that all dates, days and times are correct. Any
discrepancy is to be reported immediately to the Coordinator of the SON.
Rotations scheduled with inaccurate information are at risk for cancellation.
The confirmed clinical unit and a due date for Form B will appear on the confirmation.
If EPIC training or Loyola IDs are required for students, the date, time and place is indicated at the
bottom of the Form B under Important Clinical Information.
For changes to a confirmed clinical:
o Notify the LUHS Clinical Coordinator of any changes to the clinical as soon as possible.
o Additions submitted a week or less prior to the clinical, may not be accepted.
Note: Clinical Instructors can NOT be routinely processed on short-notice.
Form “B” - Loyola Clinical Rotation Information
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SON submits Form B at least 4 weeks prior to the start of clinical. Due date is provided on the
confirmation notice.
LATE FORM B’s (Form B’s that are submitted a week or more after the due date) may delay the start
of clinical by a week or more to allow the students and faculty the opportunity to complete required
orientation material as well as for LUHS staff to on-board the students .
A clinical group is not to be larger than 8 students. In some clinical areas (such as OB and 2S) this
number may be reduced.
Form B must be submitted electronically in a secure fashion.
Form B must have accurate information. (See form below)
Instructors/students that had not previously submitted a social security number must submit their
social security number. [Social security numbers are required to issue an Lawson number] For
foreign students in the US on a Visa, the school would notify the SON coordinator and the correct form
of identification would then be determined.
Loyola processes and returns completed Form B’s to the SON. (see form below). The SON has a
process to:
 confidentially provides faculty and each student with their personal access codes and
Lawson number provided on the completed Form “B”
 distributes information in a timely fashion so the instructor/students can access e-learning
and complete requirements prior to clinical
 makes required orientation information/documents accessible to faculty and students
Page 6 of 48
Updated 12/12/2014
Section 2 – Information for the SON
Form B – Loyola Clinical Rotation Information
During Processing Loyola
Adds:
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Last Column filled in if
Confidentiality
Statement is already on
file; resubmission is
NOT required
Lawson Number
Universal ID
LUHS Portal
EPIC Password (initial
will change)
SON completes yellow areas of
form including:
FORM B IS NOT CONTAINED IN THIS GUIDE
Faculty contact info
FORM "B" - Loyola Clinical Rotation Information
NOTE: Form B is to be completed and returned electronically 4 weeks prior to clinical start date.
Faculty/students listed are to complete required training prior to clinical. Evidence of completion is tob on file at the School per contract.
Date Submitted
Rotation Site/Unit
Semester & Year
Day(s) of Clinical
School Name
Clinical assigned Unit Name (assigned
with confirmation)
Time(s) of Clinical
Faculty/Instructor Complete Name
“on-site” Clinical Day 1
Course Number
Faculty/Instructor Contact Information:
Group Identifier if applicable
Clinical Rotation Begin/End Dates
Is Faculty/Instructor New to our Facility?
If YES, provide SS# or Loyola Employee ID:
1st Clinical Day On Site DATE:
If NO, provide Lawson Number if known:
Last Clincal Day DATE
Must provide LEGAL Nam e
Last Nam e
First Nam e
Student Social
Security #
Graduation
Year/Month
LUMC Law son LUMC UVID
Num ber
(Universal ID)
LUMC Portal
Passw ord
LUMC Epic
Passw ord
Epic Training
Date
HIPAA
Agreem ent
Returned
1

LEGAL first and last name are to be
entered in space provided
2
EPIC Training, if
scheduled, Date/
Time/Place*
3
4
5
6
7
Unless a SON can provide Lawson# ‘s, a
complete SS# is required
8
 Date/Time Pediatric
Students scheduled for a
Loyola ID
INSTRUCTOR
IMPORTANT TRAINING INFORMATION
EPIC Training Date:
Time:
Parking ID Date:
Time:
For Office Use ONLY
Skills List
Location:
Location: Parking Office, Mulcahy Bldg 106, Front Entrance, 1st Office on Right
Pyxis
IDs
Omni
Shadow ning
Logged
*EPIC trainers set the date/time of training. Every effort is
made to do the training on the first day of clinical but this is
not always possible. Factors include number of students
needing training, availability of a trainer and of a computer
training room. Training on Sunday is not available and
training on Saturday is limited.
Trinity Confidentiality Agreement
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Students must sign the User section of the Agreement. The Clinical Coordinator can sign the Employer
section of the Form as a representative of the School of Nursing. Signing the Form does not mean the
Clinical Coordinator is personally overseeing HIPAA compliance in the clinical setting. Electronic
signatures cannot be accepted.
Confidentiality Agreements must be in Loyola’s Department of Education BEFORE an
instructor/student is in a clinical area or in the “live” EPIC environment.
Loyola may occasionally require a returning instructor/student to submit another signed confidentiality
statement
It is the responsibility of the SON to have a process to insure that signed Confidentiality Agreements
are submitted to Loyola PRIOR to clinical.
E-mail delivery of individual (rather than multi-page groupings) statements is preferred.
Page 7 of 48
Updated 12/12/2014
Section 4 – Information for the Instructor
Orientation Checklist – Student & Instructor

Prior to being on a clinical unit, all students/ instructors are to complete all requirements on the
Student/Instructor Orientation Checklist.

Instructors/students (NEW and RETURNING) are to sign into e-learning (HealthStream) and
complete any assigned e-learning modules prior to starting a clinical.

If instructor/student declines the Hepatitis B vaccination for any reason, the instructor/student must
sign their School of Nursing’s waiver form which must include a release of liability statement for the
clinical site (LUHS); a notation of this should be made on the orientation checklist. The signed waiver
must be kept on file at the school of nursing.

If the instructor/student does NOT have an annual seasonal flu shot for a medical reason or
religious reasons, an Exception Letter must be submitted to LUHS for review by the Human
Resources Exception Approval Committee. [The form is found in Flu Central on the Loyola.wired).
Applications for Exemption received in Human Resources after the deadline (early November) will not
be considered
o For religious exemption the form is submitted to Lorraine Fearon, APN-employee Health
Services
o For religious exemption the form is submitted to Vicky Piper, Vice President of Human
Resources (note: social, political or economic philosophies as well as personal preferences
do not constitute religious beliefs
If the exception is approved by this committee, the instructor/student will receive written notification of
the approval status. The instructor/student will be notified of the dates they will be required to wear a
protective mask while in the health care environment. The dates are determined by flu activity locally
as reported by IDPH and CDC and communicated by Infection Control.
Persons without written approval of their Application for Exemption will NOT be allowed to participate
in clinical at LUHS.

Color blindness. A person known/found to be color-blind, must admit their limitations and take
appropriate measures to prevent errors (i.e. reading labels, asking for assistance, etc.) and ensure
safety. A color blindness screening can be found at
http://colorvisiontesting.com/ishihara.htm#demonstration

T.B. Testing: Students and instructors new to Loyola must provide documentation of a
QuantiFERON-TB Gold in-Tube test (QFT-GIT) or T-SPOT TB test to meet the T.B. requirement for
their clinical. Either one of these Interferon-Gamma Release Assay tests will be accepted. Only initial
testing is required. Subsequent testing may be warranted if T.B. exposure is suspected.
Individuals with a previous history of a BCG vaccine must provide documentation of a
QuantiFERON-T.B. Gold or T-SPOT test. These blood tests are not affected by the BCG vaccine
and do not give a false positive result.
Information regarding the Interferon-Gamma Release Assay tests can be found on the CDC website:
http://www/cdc.gov/tb/publications/factsheets/testing/igra.htm
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Submit completed checklist to the SON to be kept on file (per contract) along with any required
supporting documentation.
It is recommended that a SON retain records until student graduates or instructor terminates.
Loyola will conduct random checks to verify compliance with orientation requirements listed on the
Orientation Checklist.
Page 8 of 48
Updated 12/12/2014
Section 4 – Information for the Instructor
Clinical Areas with Requirements Unique to the Setting
Home Health Experiences
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The number of students that can be assigned to home health is limited.
The SON is responsible for informing students that access to a car is needed as student may be
meeting their nurses at a location other than the office.
Students who are in a Community clinical rotation must drive themselves to the site. They
cannot be driven by LUHS staff.
Pediatric Clinical Experiences
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A Loyola Photo ID will be required. The ID expires after the clinical is completed. Authorization
by the LUHS Clinical Coordinator is required to reactivate a student’s ID for an additional Peds
experience (i.e. clinical role transition student).
The Loyola Photo ID provides: access to:
o Access to the unit
o Access to staff bathrooms on the unit
o Access to Linen and Supplies areas on the unit
For weekend clinical: the Parking Office is closed on weekends. Students with a weekend
clinical that require a Loyola ID for Peds, can come up to 3 days before the clinical start date to
the Parking Office (Wednesday, Thursday or Friday) to obtain their ID.
OB Clinical Experiences
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The number of students that can be placed in OB is limited.
An instructor for OB is required to have a Loyola ID for unit access. The instructor is responsible
to escort their students into the area.
The key to access the dressing area is obtained from the front desk.
Instructor/students are to be dressed and ready to start the clinical experience on time. Report
times are 0700, 1500, and 1900. Clinical are to start at these times, unless otherwise
arranged/approved.
The instructor is to contact the unit manager designee Teri Boland (teboland@lumc.edu) prior to
clinical to be apprised of any requirements, changes or updates that may apply to the clinical
group
Page 9 of 48
Updated 12/12/2014
Section 4 – Information for the Instructor
Units used for Clinical Group Placement (NOT for Observation):
Unit
2APP
Description
Susan Wucka, Manager SWUCKA@lumc.edu - Unit Ext.
69567
Maternity/newborn Nursery (Post-partum)
16 bed unit
2LD
Labor & Delivery
14 bed unit
Types of Patients
Mixed in medical complexity and/ or
pregnancy related conditions
Typical Diagnoses: Pregnant, Preeclampsia, HELLP syndrome, UTI’s,
Metabolic disorders, Diabetes (Type I,
II and gestational)
Experiences highs and lows in census
Ina Ratchev, Manager ina.ratchev@luhs.org - Unit Ext.
69105
ENT Neuro
36 bed unit
Medical and Surgical
Typical Diagnoses: Thyroid Cancer,
Laryngeal Cancer, Stroke, Multiple
Sclerosis, Migraine, Brain Tumor,
Acoustic Neuroma, Spinal Surgery
Peggy Downing, Manager PDOWNIN@lumc.eduUnit Ext 64947
General Medicine Unit
17 bed unit
Michelle Ragasa Manager MRAGASA@lumc.edu – Unit
Ext. 64018
Telemetry/Cardiology/Cardiovascular
Approximately 30 beds
Medical Conditions, non-surgical
patients
Rebecca Daniels Manager redaniels@lumc.edu Unit Ext
64021
Hepatology
Approximately 30 beds
Cindi LaPorte, Manager CLAPORT@lumc.edu – Unit Ext.
66606
Pediatrics
34 Bed Unit (14 are Intermediate Care)
Surgical and medical treatment of liver
disease, Biliary diease and Liver
transplant patients
4T
Ann Edlbauer, Manager AEDLBAU@lumc.edu – Unit Ext.
61910
Acute/General/Surg Specialty
32 Bed Unit
Most are Surgical Patients
Diagnosis include Kidney Transplant,
Liver Transplant, Orthopedic Hip
procedures, Orthopedic Knee
Procedures, Whipple Procedure,
Abdominal surgeries
5NEWS
Benette Macailing Manager, mmcailing@lumc.edu – Unit Ext.
60800
Rehab
32 Bed Unit
Mixed Medical and surgical
Varying diagnoses: Stroke, Status
Post Transplants. All patients have
some functional limitation
5T
Pam Skocir, Manager PSKOCIR@lumc.edu – Unit Ext.
61700
Cath/EP/Cardio/Thoracic Surgery
32 Bed Unit
Surgical and Interventional Cardiology
Patients
Diagnoses include Post CV surgery,
thoracic surgery, Lung Transplant and
Interventional/Electro-physiology
patients
Kathleen Fujiu, Manager KFUJIU@lumc.edu – Unit Ext
69116
Oncology/General Medicine
22 Beds Unit
Janet Chiles, Manager JCHILES@lumc.edu – Unit Ext.
63986
Trauma/Surgical
30 Bed Unit
Oncology
2NE
2S
3SE
3NW
4PED
6SW
7SW
Page 10 of 48
Medical floor with some general
surgery (CV surgery, Coronary Artery
by-pass Grafts, Left Ventricular Assist
Devices
Variety of Medical and Surgical cases.
Includes Children with oncology,
orthopedic issues, Sickle Cell and
Trauma
Mostly surgical (75%) but gets some
General Medicine Patients
Updated 12/12/2014
Section 4 – Information for the Instructor
New Instructor at Loyola
A new Instructor at Loyola will need:

To meet the same requirements as the students as listed on the Orientation Checklist - Student Nurse
& Instructor.

A Lawson number (This requires your social security number) to obtain access codes required to
complete EPIC and HealthStream modules.

A LUHS ID which can be obtained from the Parking Office.


Pyxis Access – once you are processed as an instructor you will be issued a temporary Pyxis
Password. The following instructions should be followed
o A HealthStream e learning tutorial is available on the Pyxis and covers the basics of Pyxis
usage. Please take this tutorial prior to using Pyxis.
o The following instructions are used to gain Pyxis Access:
Use your UVID to log in to Pyxis
Enter the temporary Pyxis Password.
Then, Pyxis will issue the message that password is expired and will ask you to change it.
At this point, you will create your own password. (Preferably one you can remember easily as you will
not use it much once your register with your BioID). The password that you determine after accessing
the system will be reactivated for future clinical rotations.
Pyxis will then guide you through scanning your finger (choosing the index finger can be troublesome
if you get a paper cut or other injury).
It will then ask you to scan your finger 4 times. This will complete the process.

Remember login codes for future clinical rotations. Once established they will not change.

Notify the Coordinator for the School of Nursing 10 days prior to your clinical if you have not received
any of the following: Lawson number, UVID and access codes, and, if applicable, Pyxis or Omni Cell
access.

OMNI cell access is needed by instructors assigned to L&D (Areas with OMNI Cell. 6W, 6BMTU, L&D, OR





and the ED observation area)
Page 11 of 48
Updated 12/12/2014
Section 4 – Information for the Instructor
New Clinical Instructor/Student that is ALSO a LUHS Employee
If an instructor is also an employee of LUHS, they should be current on orientation requirements. The only
additional requirements that they will need to complete are:
o Initial submission of a signed confidentiality statement to the LUHS Clinical Coordinator
o Submission of their Loyola ID number to the LUHS Clinical Coordinator (used to assign a
Lawson number that identifies dual role). The instructor will use the EMPLOYEE login/password.
If the instructor was to leave LUHS employment, EPIC instructor access would be maintained as
an instructor. However, access to the portal would need to be “tweaked” to allow access as an
instructor.
Please notify the LUHS Clinical Coordinator if you are leaving LUMC employment so appropriate
adjustments can be made.
o The LUHS EPIC trainer will determine if EPIC training is needed.
o It is essential that you notify the LUHS Clinical Coordinator of what unit(s) you work on.as an
employee so that you have Pyxis access in the areas you teach and work


Portal passwords will continue to be EMPLOYEE UVID
Student Nurse - A EPIC UVID will be assigned that is only to be used when at LUHS as a student
Nurse (it will start with “dep”). When working as an employee, use your employee EPIC UVID

Must complete EPIC training required of students. Some modules may already be listed as completed
because the training requirement was already satisfied as an employee.
Let your school of nursing know that you are also an employee at LUHS. It is NOT advised that you are
assigned to the unit that you currently work on
Additional Training Requirements:

Epic Classroom Training is scheduled for instructors/students new to LUMC to prepare them for
clinical documentation. This is in addition to the required e-learning modules.
Arranging a “Shadowing Experience” for the New Instructor at Loyola:




It is recommended that the new instructor arrange a Shadowing Experience on the assigned unit
prior to bringing students.
Prior to being in a patient care area, the new instructor needs to:
o Complete all requirements on the Student and Instructor Orientation Checklist. The
exception is the EPIC modules which will need to be completed prior clinical.
During a shadowing experience, an instructor should NOT provide care, access Pyxis or EPIC.
Arrangements for a shadowing experience are arranged by the instructor by contacting the unit
manager/designate.
Prior to starting Clinical

Obtain a copy of completed Form “B”-Loyola Clinical Rotation Information from your SON. Verify the
clinical start and end dates.

Verify with your School of Nursing, prior to attending clinical, that students have:
 Completed requirements listed on the Student/Instructor Checklist
 That the completed checklist is on file at the SON
Page 12 of 48
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Section 4 – Information for the Instructor
Each FALL Term that and Instructor Returns to Loyola:
Complete Required Annual Compliance Course and Safety Courses in the HealthStream e-learning
system.
Log-in does not change. For Pyxis each term a list of instructors is sent to Pharmacy so that Pyxis
access will be activated only on the unit you are assigned. For this reason, if you are also a LUHS
employee, it is essential that you notify the LUHS Clinical Coordinator of this and what unit(s) you work
on as an employee.
First Day of Clinical
 If you plan only to tour the unit with students on the first clinical day, please let the unit know that your
students will not be taking patients.

Tour the unit and locate:
□
□
□
□

□ Nursing Station
□ Staff Bathroom(s)
□ Recycling locations
Clean Utility/Supply Room
Dirty Utility Room
Linen Supply
Medication Room
Locate/discuss Life Safety (Mandatory) Students should be able to recall location in an
emergency or if asked by a surveyor.
□ Emergency exit locations
□ Emergency operations plan
□ Evacuation/department procedures and
policies for emergencies
□ Fire extinguisher locations and types
□ Fire alarm pull-box locations
□ Standpipe and fire hose locations and
procedures
□ Everyone is responsible for safety
□ Occurrence reporting
□ Job safety hazards
□ Location of material safety data sheets
(MSDS)
Clinical Time
o Clinical scheduled during the times of 0700, 1500 or 2300 requires that the clinical group is
prepared to be present on the unit and ready to listen to report. It takes up valuable nursing time
to have to repeat report because a student or student group does not come to report or does not
have their assignment.
o Adherence to clinical time includes off-unit observational experiences. If the experience is
scheduled for 0700, the student is to be in the assigned area and ready to start at that time.
Clinical Group Size
Clinical group size for an instructor is limited to no more than 8 students. In some clinical areas such as
OB and 2S, this number may be reduced. It is expected that the instructor is able to work with a clinical
group of up to 8 students.
Page 13 of 48
Updated 12/12/2014
Section 4 – Information for the Instructor
Arrangements for Clinical Meeting/Conference Room
o
o
o
The Department of Nursing Education does NOT schedule rooms for the SON.
Meeting rooms are in short supply.
Instructors can check with the unit manager/designate to see if a room is available on the unit.
The meeting area must not be in a public area of the hospital in keeping with HIPAA compliance
and patient confidentiality.
End of Clinical Term
 Each clinical instructor is expected to complete LUMC clinical evaluation by the end of Each Clinical
Term.
Survey Site: https://www.surveymonkey.com/s/X2CDXF9
Locate Survey by Title: LUMC clinical Instructor Evaluation of Site
Page 14 of 48
Updated 12/12/2014
Section 4 – Information for the Instructor
Clinical Instructor Role in the Supervision of Student Nurses at LUHS
The role of the Clinical Instructor includes but is not limited to the listed professional responsibilities:
o To assure adequate supervision of the student nurse in performing skills for which the student
has the educational foundation to perform safely.
o
To oversee the care provided by nursing students
o
To review student documentation and enter a Nursing Note in EPIC verifying that student
documentation was reviewed. An Instructor can create their own “smartPhase” if desired. For
example:
Reviewed ***(SON name) student ***(student name) shift documentation from
today and I agree with student documentation.
The *** marks indicate where the SON name and student name would be filled in. This
documentation would take place at least 1x/shift (regardless of whether the student shift is 6, 8,
or 12 hours). This would service as a cosignature, showing the instructor signature.
If the instructor does NOT agree with student documentation, the “Note would reflect this” and the
instructor would need to write an addendum to the documentation.
[In precepted clinical situations, the preceptor would review student documentation and co-sign.]
o
To be on the assigned unit when students have patient assignments. (Note: not applicable for
students with preceptor arrangements)
o
For maintaining patient and student safety in the clinical setting. This includes being aware of
any limitations placed on student participation in specific clinical areas.
o
To act in collaboration with the clinical staff.
o
To demonstrate professional behavior and serve as a professional role model.
o
To be visible and actively engaged with students on the unit. (Note: not applicable in student
with preceptor arrangements)
Contact the LUHS Clinical Coordinator and unit manager with any questions and/or issues related
to your clinical experience.
Page 15 of 48
Updated 12/12/2014
Section 4 – Information for the Instructor
Forms for Use on the Clinical Unit
Student Skills List (Available in Appendix)
A School of Nursing Course Coordinator/Instructor completes a course List of Skills. A copy is sent to
Loyola’s School of Nursing Coordinator
1. Annually, a School of Nursing Course Coordinator reviews the list and notifies Loyola of changes.
2. The Clinical Instructor fills in the middle portion of the form with their name, clinical days, dates
and times of the clinical.
3. Each clinical day the Instructor posts the Course Skills Checklist on the assigned unit in the area
designated by the Unit Manager/Designate.
4. At the end of the clinical day, the Instructor removes the posted list.
Student Nurse Patient Assignment Sheet (Available in Appendix)
The purpose of this form is to provide staff with an overall view of student assignments on the unit.
1. The Instructor/Student verbally notifies the Nurse responsible for the patient of:
 Student assignment to the patient and
 If the student will be passing patient medications.
2. Once the nurse has been verbally notified, this sheet is to be posted by the Nursing Instructor in
the area designated by the Nursing Unit to serve as an overall view of the student assignments
on the nursing unit.
3. This sheet is to be removed by the instructor at the end of the clinical day. In some clinical areas,
the practice maybe that the unit keeps these sheets. Please check with the manager, assistant
manager or charge nurse if the unit wants to keep these sheets.
Page 16 of 48
Updated 12/12/2014
Section 5 – Information for the Instructor and Student
Skills that Nursing Students are NOT allowed to perform at LUHS
Skills that the student nurse cannot perform include but is not limited to those listed
below. The student nurse at LUHS is NOT allowed to:

Administer medications without appropriate licensed oversight.

Administer blood or blood products.

Care for patients requiring airborne isolation where a N-95 Respirator Mask is
required

Initiate the placement of patient restraints.

Witness consents.

Administer chemotherapy.

Titrate drugs.

Perform skills or procedures that the student does NOT have the educational
foundation to perform safely

Waive Testing/Point of Care Testing (for example: use of a Glucometer)
Page 17 of 48
Updated 12/12/2014
Section 5 – Information for the Instructor and Student
Observational Experiences for the Student Nurse
Description
 An observation/shadowing clinical experience is defined as the observation of a health care
professional in their professional role.
 An observational/shadowing clinical experience is an additional or alternative experience to the
designated primary clinical placement unit/area.
 Observational sites include Critical Care and Speciality areas. Units used for clinical placement
of groups of nursing students are NOT to be used for observation.
 Designated primary clinical placements take priority over observational experiences.
 Observational Experiences are not guaranteed - the manager/designate has the right to
cancel/terminate the experience. Common reasons for canceling are related to staffing needs,
census, and orientation of unit staff.
 Observation is an additional experience that can enhance the student learning experience.
However, these experiences are limited in availability. Observation are not used for the purpose
of reducing instructor student load.
Process for arranging an Observational Experience
 The instructor contacts the manager/designate of the unit/area to request an observational
experience at the BEGINNING of the clinical rotation.
 Prior to the arranged experience, instructors are to provide the manager/designate:
o Student Name
o Date/Time of Experience
o Instructor Contact Information
During an observational/shadowing clinical experience:
 The instructor is available on-site
 Students are expected to be at the assigned location on time and, if applicable, ready to listen to
report (report times are 0700, 1500 and 2300) .
 Students must comply with all unit rules and regulations.
 Students may NOT administer medications, perform hands-on care or procedures during the
experience.
 As a learning opportunity the nurse may invite the student to listen to patient breath sounds, heart
sounds, bowel sounds or palpate patient pulses with the nurse.
 The student may assist the nurse in activities that do not involve hands on care or procedures.
For example, assisting in changing a bed, removing a food tray after the nurse/PCT has
determined I&O.
 A student in an observational experience does not document in the medical record.
Page 18 of 48
Updated 12/12/2014
Section 5 – Information for the Instructor and Student
Critical Care Areas – Only available for Observation or Preceptor Experiences:
Unit
Description
Peggy Downing, Manager PDOWNIN@lumc.edu
Unit Ext. 60997
Observation
Currently 10 bed unit (has capacity for 13)
1T
Short-term observation. Most patients from
Emergency Department and do not meet
admission criteria
Jennifer Booth Manager Jennifer.Booth@luhs.org
Unit Ext.68591
Cardiovascular ICU
16 bed unit
2ICU
Teresa Rasmussen Manager trasmu1@lumc.edu
Unit Ext. 62200
Neuro ICU
13 bed unit
2W
3HTU
3MICU
4ICU
Meghan Slade-Smith Manager mssmith@lumc.edu
Unit Ext. 68755
Heart Transplant (ICU)
10 bed unit
Barb Pudelek, Manager BPUDELE@lumc.edu
Unit Ext. 63575
Medical ICU
16 bed unit
Kathy Przybyl, Manager KPRZYBY@lumc.edu
Unit Ext. 64265
Trauma/Surgery Intermediate Care
24 bed unit
Unit
4PICU
5R
6BMT
7BICU
7N
Description
Cindi LaPorte, Manager CLAPORT@lumc.edu
Unit Ext. 64660
Pediatric ICU
14 Bed Unit
Theresa Martinez, Manager
THMARTINEZ@lumc.edu
Unit Ext. 68261
Neonatal ICU
50 Bed Unit
Heather Hedlund, Manager.
HHEDLUND@lumc.edu
Unit Ext. 64959
Bone Marrow Transplant (ICU)
8 Bed Unit
Jeanie Leggett, Manager JLEGGET@lumc.edu
Unit Ext. 63988
Burns ICU
10 Bed Unit
Jeanie Leggett, Manager. JLEGGET@lumc.edu
Unit Ext. 63982
Burns
11 Bed Unit
Other Potential Observational Areas (in addition to the critical care areas above)
The following list is some possible sources of observational experiences, an instructor might consider.










Bessie Baldovino (In-patient Dialysis) bbaldov@lumc.edu
(GI Lab Manager) Julie Johnson juljohnson@lumc.edu
Lisa Lehner (Clinical Educator of Surgical Services) LLEHNER2@lumc.edu
Mary Grace Mora-Lach , EP lab Assistant Manager mmora@lumc.edu
Jennifer Schramm (Day Hospital Cancer Center Manager) jeschramm @lumc.edu
Kristin Dombrow ( Ast. Manager ED) kdombro@lumc.edu
Robyn Thurston, Practice Director, OB-Gyne and Women's Health (Only for students in OB in times of low census)
o RTHURST@lumc.edu or 708-216-8395
Susan Finn, APN – Pediatric Mobile Van (Only for students on day shift in Pediatrics) sfinn@lumc.edu
Cancer Center Day Hospital Manager Jennifer Schramm JESCHRAMM@lumc.edu
Cancer Center High Dose Therapy Manager Heather Hedlund HHEDLUND@lumc.edu
The Wound/Ostomy Nurses and/or PICC Nurses are NOT be followed unit to unit as an observational experience. If the
Wound/Ostomy nurse is seeing a patient on the assigned clinical unit, the instructor may request for a student to observe the
Wound/Ostomy nurse during the encounter. The patient should be advised of the role of the student.
Page 19 of 48
Updated 12/12/2014
Instructions For Undergraduate Nursing students to Complete Loyola’s Required
HealthStream E-Learning Courses
NOTE: HealthStream E-Learning courses must be completed in Internet Explorer. Do not use other
browsers, such as Firefox, Safari, Google Chrome, etc. as HealthStream, E-learning application, is not
compatible with these browsers and not supported in versions of Internet Explorer >8.
HealthStream E-learning Instructions:
1. Go to E-Learning via the Trinity HealthStream website:
www.healthstream.com/hlc/trinityhealth
2. Log on using your LUMC Lawson number:
For the USER ID enter: lu + your Lawson code.
For the Password enter : lu + your Lawson Code.
3. After logging into HealthStream, you will see that you have been automatically enrolled in
4 HealthStream modules. You may also be enrolled in several mandatory Trinity
modules. Complete those as well. For any E-learning module that has a quiz/exam, a
score of 80% or better is required to pass.

The organization requires 4 Healthstream courses for every student:
 LUMC 2014 Annual Regulatory Compliance Competencies- All Staff
 LUMC Annual Safety Competency 2014
 LUMC Restraint Use 2014 Nurse Version
 LUMC Be Safe Falls Risk Guide-RN Version
Page 20 of 48
Updated 12/12/2014
EPIC E-learning Instructions:
4. Use the Catalog tab on the Trinity HealthStream Home page to access the Undergraduate
in patient EPIC modules.
5. Enter LUHS-EPIC-INP Epic CBLs for Nurses and Nursing Students in the Search
box:
6. Select LUHS-EPIC-INP Epic for Nurses and Nursing Students
Page 21 of 48
Updated 12/12/2014
7. Then select and complete the following EPIC modules:
8. Upon completion of each course, please click on the Submit button and then “X” out
of the lesson. You should remain in HealthStream. The following example is what a
Completed course will look like.
Page 22 of 48
Updated 12/12/2014
9. Due to computer system compatibility issues, the completed courses may NOT appear as
completed or denote a score. Contact EPIC trainer Bindiya Shah (bshah@lumc.edu) for
assistance.
Printing a Transcript from E-Learning
1. From the Trinity HealthStream home page click on the My Transcript tab.
2. Click on Customize and Print Transcript – Enter parameters and click on continue button.
3. Click Print and provide this transcript to your clinical instructor. Your transcript stays in your file at
school.
Page 23 of 48
Updated 12/12/2014
E-Learning Assistance
If you cannot log into E-Learning or have any trouble within HealthStream, please contact the Loyola
Help Desk: 708-216-2160.
Page 24 of 48
Updated 12/12/2014
Purposeful Hourly Rounding
Hourly rounding has been shown to be a statistically significant path to improve patient experience scores,
decrease patient falls, and enhance patient safety measures. Purposeful Hourly Rounding was initiated as a
program at Loyola in January 2013.
Hourly Rounding is called “4P’s with Purpose” and it is the expectation for care provided on all hospital units. The
4P’are Pain, Positioning, Personal Hygiene, and Personal Needs (for example, having a call light, and tissue box
within reach). During the admission process, the nurse educates the patient to expect either the nurse or patient
care tech to check on them regularly every hour to see that the patient’s pain, positioning, personal hygiene and
personal needs are met. This creates expectations; when we fulfill the patient’s expectations, we create trust.
This ensures a consistent experience no matter where in the hospital a patient receives care . Hourly rounding is
“purposeful” in that it is proactive and anticipates the patient’s needs.
Each shift begins with a Team Huddle, Bedside Safety Hand-Offs to introduce the patients to the oncoming care
team, with a reminder that Purposeful Hourly Rounds will be completed every hour of the day and night. (On most
units, RNs round on even hours and PCTs round on the odd hours.)
During hourly rounds reintroduce yourself and your role and let the patient know “I am here to do your hourly
check”. After completing any care activities, ask the patient “What else can I do for you? I have the time”. Before
leaving the room, tell the patient “We will check on you again at ___o’clock” and write the time of the next round
on the patient’s whiteboard. If a patient wishes to sleep undisturbed, a note is left at the bedside, informing the
patient when the next staff member will be expected to do rounds.
Specific actions, words, and behaviors are used to assess and meet patient needs. “Key
Words at Key times” helps to reinforce our message of caring, and our desire to meet the patient’s personal needs.
Personal Needs mean more than ensuring that the patient has all their possessions within reach – it’s about
making a personal connection with the patient and listening to what the patient may want to share with you. The
following is an example of using key words:

Privacy: “Let me draw the curtain for your privacy”

Comfort: “Here, let me reposition you so you will be more comfortable”

Safety: “We always verify two patient identifiers before giving you medicine – this is for your safety”
If a situation occurs where the nurse can not get to the next scheduled round, it is the nurse’s responsibility to
communicate this to the charge nurse. The charge nurse will either have the assigned PCT complete the rounds,
assign the rounds to another staff member, or personally step in to complete the rounds.
Daily Huddles
Daily Huddles are conducted daily at 7 am on each patient care unit between the night and day nursing staff.
Students and instructors are required to attend these huddles to coordinate patient assignments and patient care.
Page 25 of 48
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Page 26 of 48
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Page 27 of 48
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JOINT COMMISSION PREPAREDNESS
Please make sure you are prepared in case you are asked questions they by a Surveyor. Please be aware that a survey can
occur at any time and everyone must be prepared.
Students should be able to identify where the safety locations are (i.e. fire pull stations, exits, extinguishers) and relate
completion of e-learning training/testing covering topics of safety and compliance.
Please be vigilant to keep our patients safe. Patients are NOT to be left unattended in hallways. “Immediate threat-to-life”
can be issued by a surveyor if an unattended patient is found without a call light or a way to summon for help OR without
a hospital caregiver within the patient’s line of sight.
Advice on how to respond to a surveyor question:






When a surveyor asks to speak with you, please make sure your patient(s) are covered by another nursing unit
member
Be friendly and relaxed
Be sure you understand the question
After giving it some thought, answer the question.
If you do not know the answer, tell the surveyor where you can find the answer or who can help provide it - use
your life-lines.
Stop talking once you have answered the question.
Advice on what to do if a surveyor asks a co-worker a questions:


Work as a team
Volunteer to help you co-worker answer a question OR offer to cover their responsibilities while our co-worker is
speaking with the surveyor
Students/Instructors may need to be able to demonstrate or relate:





Where the units life safety locations are (i.e. fire pull stations, fire exits, fire extinguishers)
Orientation checklist items which included the annual safety and compliance e-learning modules were completed
prior to starting clinical
How patient’s rights are protected
o Some examples:
 planning care to meet patient needs
 ensuring that patients receive prompt and effective relief for pain)
How patient privacy and confidentiality are protected (for complete list see Patient's Bill of Rights posted in
lobby)
o Some examples:
 following HIPAA guidelines before releasing patient information
 ensuring only authorized persons review patients' records
 Logging off computer screens
 Not talking about patients in public areas
 Knocking on the patient's door before entering
Efforts to improve Quality and Patient Safety - PURPOSEFUL HOURLY ROUNDING
o review attached document (Purposeful Hourly Rounding)
o do Purposeful Hourly rounding as assigned
Page 28 of 48
Updated 12/12/2014
National Patient Safety Goals






Right Patient - Use of TWO patient identifiers (name and date of birth) every time you administer
medications/blood, obtain lab samples, and perform procedures.
Effective Communication - includes reporting, responding to and documenting all critical test results
Safe Equipment Use
Safe Medication Use (includes label medications and solutions, check expiration times, use of standard protocols
i.e. anticoagulation protocols, and reconcile medications.
Prevent Infection - Hand hygiene before and after any patient encounter; use personal protective equipment;
follow isolation guidelines to prevent the spread of infection; prevent central line infections by following protocols
for insertion and maintenance; prevent surgical infections.
Patient Assessment/Education - educate patient and family on infection-control strategies; Identify patients at risk
for suicide and address immediate safety needs; address home safety (falls, long-term oxygen safety); educate
patients and families to share their concerns related to quality or safety
Loyola Emergency codes:










Code blue - Medical emergency (in hospital dial 6-9990 to report)
Code Red - Fire [RACE=rescue, alarm, contain, extinguish] Fire extinguisher use - PASS (Pull the Pin, Aim at the
base of the fire, Squeeze the handles together, Sweep from side to side) If a fire occurs in another area: Close all
doors and wait for further information or a "Code Red-All clear"
Code Gray - Security response
Code Pink - Missing Infant/Child
Code Black - Severe Weather Alert Watch/Warning
Code Purple - Evacuation
Code Green - Utility Failure/Outage
Code Orange - Hazardous Material Spill/Release
Code Triage - Disaster Plan Activation (internal, external or standby)
Hazardous Materials - Refer to Safety Data Sheets (SDS) for detailed information and safety precautions. Located
on Loyola Wired under Employee Resources and scroll under the "Health Resources" section to Safety Data
Sheets
Disposal of hazardous materials:






Red biohazard containers/bag: sharps, blood drainage-soaked dressing, disposable items that could release
blood or infections material if compressed, IV tubing with visible blood and ALL specimen transport bags.
Soiled Linen bag - All clean and soiled linen
Yellow Chemo Container - All chemotherapy items
Black Pharmaceutical Containers - Pharmaceutical waste
Containers/bags labeled "Radioactive" - Only Radiation Control is authorized to remove
Clear Trash bag: Use to dispose of everything else
Page 29 of 48
Updated 12/12/2014
Joint Commission Preparedness (cont’d)
Cleaning of Equipment:
 Bleach wipes - "wet-times" 30 seconds to one minute for most organisms; 2 minutes for tuberculosis; 5 minutes
for Aspergillis niger
 Cavacide spray and wipes: "wet-times" 2 minutes for most organisms; 3 minutes for tuberculosis.
Important Contact Information






On-campus emergency - Call 911
Off campus emergencies - Call 9-911
Patient Safety Hotline - Call 708-327-SAFE
Environmental Safety Concerns - 708-327-2334; SAFE4
Loyola.Wired (Loyola Home Page) for everything you need to know
Joint Commission Web site – www.jointcommission.org
Patient Identification
Patient identification must be performed prior to any critical task. A Critical task is task or procedure in which there is a
significant possibility misidentification could result in harm. Examples of Critical tasks include but are not limited to:










Placing a band containing protected health information on the patient
Surgery
Taking blood samples or other specimens
Blood Transfusions
Medications and intravenous administrations, including sedation/analgesia
Sleep studies
Procedures
Transporting patients from one department to another
Delivering patient food trays and snacks
Distributing paperwork with PHI on it
Before any Critical task, the patient must be identified using:


Full name
Date of Birth (DOB)
The preferred method of identification is to ask the patient, “What is your name and date of birth?” The name and DOB is
then compared to the name and DOB on the patient’s band or with an alternative method of identification. If a patient is
unable to self-identify, alternative methods of identification include comparing the name, DOB, medical record number or
information available at the time of admission found on : Computer generated forms such as the EMR, lab generated
labels, physician order, requisition, transfer forms, ambulance/emergency transport records or SBAR. Once the patient’s
identity has been verified, match the name and DOB on the Critical task paperwork in n the EMR to the patient.
Page 30 of 48
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Medication Administration

Nursing Students administer medications ONLY under the supervision of a licensed nurse. This is
noted by writing a comment on the MAR.
Comment Examples:
o med given under supervision of Instructor Doe
o med given under supervision of Nurse JD (initials can be used to identify the nurse)
o Medications are administered and charted using Bar code scanning. It is the expectation that
the students will have 100% compliance with the Bar code scanning process.

Medication Policies - Highlights
o There are multiple medication policies that promote safe patient care. For additional information,
refer to the actual policy and procedure in the Patient Care Policy Manual on Loyola.Wired.
o The following are some “highlights” found in Loyola’s medication policies:
 Prior to administering any medication, check the electronic MAR in EPIC and verify the:





o
o
o
o
o
Right drug
Right dose
Right route of Administration
Right Time and Frequency of Administration
Right Patient (two identifiers)
Remove medications from Pyxis for only one patient at a time. After these meds are
administered then medications for another patient can be removed.
Medications that do NOT require preparation should stay in the original packaging to be
opened at the bedside. Medications prepared prior to the patient’s bedside must be labeled
with medication name, dose and date.
2 patient identifiers must be verified before administering any medication.
Never leave medications unattended. Medications must be immediately transported to the
patient.
High Risk/High Alert medications require an independent double check documented
simultaneously in the EMR in the drop-down box that appears. When performing an
independent double check 2 Nurses separately check:


the 5 Rights of medication administration
independently verify calculations
trace the IV tubing from the bag through the pump to the insertion port

High Risk/High Alert Medications include:







o
o
o
o
All routes of insulin (includes rate changes)
Parenteral opiates
Chloral hydrate
Concentrated electrolytes
Chemotherapeutic agents
Neuromuscular blocking agents
TPN/PPN


Look-alike, Sound-alike medications
Intravenous anticoagulants:

Low Molecular Weight Heparin

Bilvarudin

Aragatrolba

Lepirudin
 Alteplase (except catheter
occlusion)
Medication - Pain Reassessment
Suggested intervals after PRN pain medication administration
o PO/NG medications – reassess 60 minutes following administration
o Subcutaneous/IM medications – reassess 30 minutes following administration
o IV medication – reassess 15 minutes following administration
Document after intervention for pain should be within 4 hours after pain medication is
administered. If Pain persists, notify physician for breakthrough dose, dose change, a change in
frequency, or an order for a different medication.
All pain medications given must be documented within 1 hour of administration.
Page 31 of 48
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Overview / Guidelines / Policy

Cell Phones and Other Wireless Devices
o
o
o
o

Electronic devices/telephones can NOT be used for personal use. Students must turn off
personal cell phones during work hours. At lunch or break times, personal cell phones can be
used outside the medical center buildings or in an area designated by the department manager.
Allowed is electronic device/telephone use for the purpose of accessing clinical information (i.e.
looking up a medication or diagnosis). However, the student should verbalize to the
patient/staff/instructor in the vicinity the reason for use to prevent the perception that the device is
being used inappropriately. At NO time is a camera, video or recording device to be used in the
clinical setting.
Instructors are responsible to monitor student use of such devices to insure use is appropriate.
Students should be encouraged to use the reference materials available through Loyola.wired in
the clinical setting.
Students must obtain supervisory approval to carry a personal pager at work. If approved, the
pager must be used in the silent or vibrating mode.
Computer Access, Omni Cell or Pyxis Help
Please contact the appropriate resource for assistance if you forgot your codes or are experiencing
difficulty with Computer, Omni Cell or Pyxis access:
 Student/Instructor
 Computer Access – contact the HELP desk at 708-216-2160
 The Clinical Coordinator should be contacted ONLY if instructed to do so by the HELP
desk
 Instructor
 Pyxis access – contact the Clinical Coordinator
 Omni Cell – contact the Clinical Coordinator

Computers / Telephones / Nursing Station
The computers on the units are not to be used to receive or send personal E-mails. Students should
not use chairs in the nursing station to socialize with other students.
Telephones in offices, nursing stations and corridors are only for business purposes and should not
be used for personal calls.

Dress Code
All students are required to wear their student nurse uniform and Picture ID. Each SON has a dress
code for students. The following are "highlights" from Loyola's dress code policy (last revised 5/2011)
that should also be considered by students/faculty in clinical at LUHS.
o
o
o
o
o
o
Nails - No acrylic nails; nails no longer than 1/4 inch long. Nail color, if worn, should be conservative and
well maintained. No nail ornaments.
Uniform - clean, neat, well fitting
Hair - clean and groomed. Extreme hairstyles and/or extreme colors (like pink, purple, blue, etc) are not
acceptable. Beards and mustaches must be neatly trimmed
Minimal jewelry. No more than 2 conservative, discreet earring on each ear. One simple necklace may be
worn. Bracelets will not be worn -- exception is medical alert bracelets Wrist watches are acceptable. A total
of 2 rings are acceptable - one on each hand. Facial jewelry is unacceptable (exception being 1 small
discreet stud, worn mid-nare. Tongue studs, if worn, must not be visible.
Tattoos must be covered.
Feet - stocks/stocking must be worn at all times, Shoes - high-top, multi-colored shoes, boots, open-toe
and/or shoes with holes (Crocs) are not acceptable.
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Additional Dress Code Considerations for Students
Students should be in school uniforms (unless on a unit that requires the use of hospital scrubs).
Photo IDs are considered to be a part of the uniform.
Warm up jackets as part of the student uniform is acceptable. Students should NOT be wearing their
lab coats on a unit. At Loyola, the style, color and length of a lab coat is determined by the title/tank
and provided by the hospital. The lab coat has the individual’s name, title and hospital’s logo on the
coat.
Dress Code for Nursing Instructors
Nursing Instructors should adhere to the LUHS Uniform policy found on Loyola.Wired under Dress
Code. The instructor’s uniform must be clean, neat and well fitting. The instructor must have
professional attire appropriate for the clinical experience.

Drug-Free Workplace
Loyola University Health System has a commitment to a safe and drug-free workplace. To ensure a safe workplace anyone
providing service for Loyola University Health System is expected to report for work fit for duty, which means able to perform job
duties in a safe, appropriate, effective manner showing concern, respect, care and cooperation with coworkers, patients and visitors.
If you are concerned about someone’s ability to meet these criteria, your role is to report your concerns immediately.
Substance abuse or dependence can be difficult to identify. Typically, it is surrounded by avoidance and denial. You do not have to
diagnose a problem, but you play a big role in recognizing when the possibility of abuse or dependence might exist.
If you are concerned that someone may be under the influence of alcohol or other drugs, you should immediately notify the
department manager/designate. Human Resources is also available for assistance. While it is sometimes difficult to make a report,
remember that substance abuse and dependence can be life threatening. By intervening you may help the person get much needed
help.

HIPAA/General Compliance Violations
HIPAA covers patient information whether in written, electronic or verbal communication formats.
Students may only access patient information, whether in EPIC or elsewhere on their assigned
patient(s). Accessing records of other patients is a HIPPA violation. Patient information must not be
shared outside of LUMC and it is not permissible to remove patient information, including on personal
devices, such as a cell phone, from LUMC at any time. Patient information may not be discussed in
public or visitor areas and/or locations where it may be overheard by individuals not involved in the
patient’s care. Disclosing or sharing patient information with individuals not involved in the patient’s
care may result in a HIPAA violation. Any privacy concern or possible violation must be promptly
reported to the LUMC Organizational Integrity Department at 708-216-2036.
Any HIPAA or general compliance violation may be remedied by terminating the student or trainee’s
participation in the educational activity at LUHS and terminating the entire relationship with the
educational entity (i.e., subject to the terms of any applicable affiliation agreement). Violations may
also be subject to civil monetary and criminal penalties.
LUHS Administrative policies regarding HIPAA can be found on Loyola Wired. The following are key
HIPAA policies:
1. Access to, Release, Use and Disclosure of Protected Health Information
2. Access to and Release of Patient Information-Students, Trainees, Agency Staff and Volunteers
3. Email, Internet and other Social Media Service Usage
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
Identification Badges
o
o
All students and faculty are required to wear a photo ID badge when participating in a nursing
clinical throughout LUHS. Photo IDs must be displayed on the outside of the uniform and clearly
list the first and last name and status ( faculty or student )
The following circumstances that require a Loyola (LUMC) photo ID:




o
o
o
Maywood Campus Loyola School of Nursing Students (ABSN)
Faculty and Students in Pediatrics are required to have a Loyola ID
Faculty in OB are required to have a Loyola ID
Faculty that need access to medication and supply areas on the clinical unit will require a
Loyola ID [NOTE: Instructor IDs that deactivate need to be replaced or reactivated.
This can occur in 3 year cycles].
Loyola IDs are issued in the Parking Office located in the Mulcahy Building, Room 1606. Contact
the Parking Office with questions at 708-216-9092.
The cost for replacing a lost Loyola picture ID is $10.
Students are encouraged to purchase their parking pass when they come to get their IDs from the
Parking Office.

Injury on the Job
o
If an injury occurs on the job, you should report it immediately to your supervisor.
o
A student safety event can be entered using the Patient Safety Event or Near Miss report form. To
access this form and file a report:
1.
2.
3.
4.
o

According to the contract, “Loyola shall provide emergency medical care for the Student(s) of School
participating in the program that require such care. Each student receiving emergency medical care or any
other type of medical care at Loyola shall be responsible for paying for such services rendered by Loyola”
Parking










Go to Loyola Wired. From the list of Online Resources click on Patient & Employee Safety.
The Culture of Safety Screen will appear. Under Patient Safety click on the gold button.
A log-in screen will appear. Log-in using your user ID and password.
Complete and submit the online form
Students/faculty are NOT allowed to park in visitor parking and will be ticketed.
All students are allowed to park in the free gravel lot OR they can purchase a value pass (key
card).
The value pass (key card) allows the student to park in Deck “B”.
The value pass can be purchased for the number of “expected visits” with cash, check or charge
at the Parking Office.
The cost of the value pass is $2.00 for EACH visit. Thus, leaving the parking deck and returning
on the same day counts as 2 visits.
If a pass is needed for more than 10 times in a month, a monthly pass can be purchased.
Contact the Parking Office for details and cost.
The Parking Office is located in the Mulcahy Building, Room 1606. The hours are 7:45 to 4:45,
Monday, Tuesday, Thursday and Friday. On Wednesday the hours are 7:45 to 1:00 PM.
When visiting the Parking Office, students can park for free in Lot 10 for 30 minutes or less while
they are obtaining a parking pass. The Parking Office will issue a token to exit Lot 10 without
charge.
Contact Parking with questions at (708) 216-9092
Respectful Workplace
Loyola fosters an environment that embraces diversity. It is part of our mission. Therefore jokes,
cartoons or other materials that refer to age, race, religious background or gender should be avoided.
Page 34 of 48
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
Sexual Harassment
Loyola University Health System and the Stritch School of Medicine are committed to a workplace
environment that is free from sexual harassment. All complaints of sexual harassment will be thoroughly
investigated and addressed through the LUMC policy on sexual harassment (LUMC Human Resource
Policy G-13).
The term sexual harassment means unwanted and unwelcome sexual attention on the job. Sexual
harassment may be:




Verbal, physical, or visual and includes written, printed, and electronic communication
A request for sexual favors in exchange for something else such as a pay raise or promotion
Interfering with an individual’s job performance
Creating and intimidating or hostile work environment
What you may view as harmless may be objectionable to others. It is not the intent of the sender of
behavior that counts; it’s the impact on the recipient. Examples of sexual harassment may include:
•
•
•

Inappropriate jokes or sexually oriented language
Nude or semi-nude photos, posters, calendars, or cartoons
Introduction of sexual topics into business conversation
Smoking
Smoking is not allowed anywhere on Loyola property or in vehicles in parking lots.

Solicitation or Distribution of Literature or Goods
No solicitation or distribution of any kind is allowed in work areas during working time.
Page 35 of 48
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Resources Available to Students/Instructor

Loyola Patient Care Policy and Procedures
o
o

Can be found by going to Loyola Wired, choose the Policies tab, under Policy Manuals choose
the Patient Care Policy Manual. In the Patient Care Policy Manual locate the policy needed
under the appropriate headings.
The majority of policies used by nurses are under the following headings: Infection Prevention
and Control, Medication, Patient Care w/Equipment &/or Supplies, Pain, Risk
Management/Patient Relations/Legal, Falls and Restraints.
Medical References
The following medical references are found listed under emr.lumc.edu clinical information resources
o Clinical Pharmacology (medication information)
o Patient education (materials for patient education)
o Medical Record Abbreviations
o Parenteral Mediation Administration Guidelines – Adults
 Found under Clinical Protocols page listed under All services.
 Agents listed in this document are considered formulary unless otherwise indicated

Library
Once on the Health Sciences Library site look under “Resources For” and choose “nurses”
Provides access to Data bases, journals, books, guides, etc.
On-line Health Science Library Resources for Nurses
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Appendix
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Logging into Epic Hyperspace
 At the Department Selection window, select the Nursing
Unit on which you will be working.
Results Review


Opening a Patient Record

 You can open a patient’s inpatient chart in 2 ways: either
Nursing Student
QUICK REFERENCE
Select Results Review from the activity toolbar.
Click on the Time Mark icon to indicate that you have seen
the results.
If there are no new results, click on the ‘Click here to move
to the extended view’ hyperlink.
To graph results, highlight the values you wish to graph and
select the Graph icon.
To graph non-adjacent results, from the ‘tree’ of results
click on the first result and then hold down the control key
on the keyboard and click all other non-adjacent results.
double clicking on the patient from a system list for the
nursing unit or select Hospital Chart from the top toolbar
and enter the patient’s MRN or last name, first name.
 When opening a patient record using the top toolbar, STOP
at the Contact Selection Screen and select the correct
inpatient encounter (contact).

Patient Reports
Medication Administration Record (MAR)


Patient Care Summary
 Select Add/Edit comment link in the upper right corner
of the Patient Care Summary to free-text comments
about the patient (i.e. limited understanding of English)
Adding and Removing a Report Button
 Select the Wrench Icon.
 Place the cursor in the blank field to display the
magnifying glass.
 Select from the magnifying glass or drop down menu
the report you wish to have as a shortcut button.
 To remove a report shortcut button, select the Wrench
icon, highlight the report name and press the delete
key on the keyboard.
Chart Review











Select MAR from the Activities Toolbar. Overdue Meds Report
will appear if any medications are overdue. The report links directly
the dates and times of the overdue medication.
To document med administration and/or to access the
administration detail screen to make comments or change
administration time, click on the administration time shown.
If the administration is late, click on the administration time
and enter the correct time on the detail screen.
When documenting the administration of a medication,
enter “GIVEN UNDER THE SUPERVISION OF A LICENSED RN
(with the initials of that RN)” in the comment field.
Inpatient Immunization administration is charted in the
MAR.
The MAR report in the MAR shows active medications for
one, three or seven days
Click on Chart Review from the activity toolbar.
Select from the Chart Review tabs to access the
information you wish to view.
Use the Filters button to find specific information.
Click Clear Filters to clear the filters.
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Locating Consent/Forms
Click on Chart Review, then Media tab to locate consent forms
and other scanned documents. Double-Click a row entry to
view a scanned document/consent. Keep in mind, that there
may be several consent forms for various treatments or
procedures.
Viewing Notes
To view notes that are specific to the current encounter, select
the Notes button from the vertical activity toolbar. All notes for
the current encounter display by default. There are note tabs at
the top of the window that allow you to view specific note types
(i.e. procedure notes, progress notes, etc.)
To view notes across the entire patient continuum of care, select
Chart Review from the activity toolbar. Select the ‘Notes’ tab.
Use the filter activity to filter the notes by user type, author,
encounter, and various other filtering options.
Documentation Flow sheet






Select Doc Flowsheet from the Activities Toolbar.
Note that certain flowsheets display by default for the
particular nursing unit you sign onto such as “NSG Vitals”,
“NSG Head to Toe”, ‘Intake” and “Output”.
If additional flowsheets are needed, select the desired
flowsheet from the ellipsis.
Click “Insert” column, if charting data that was taken at an
earlier time. Adjust the time to the actual time the data was
collected.
Click “Add” column to add a column for the current time.
Some cells require manual entry of data, such as height and
weight. Other cells require answers that are contained in a
custom list. Open the ‘Detail’ box to view and select from all
available options.
Date shortcuts
Note Entry (PIE and free text)





Click on the Notes button on the Activity Toolbar. Choose
the “New Note” button.
Select the appropriate note type from the drop down
menu (i.e. NSG PLAN OF CARE)
To write the Plan of Care note using the established
template, click on the “Insert Smart Text” icon (three
sheets of paper) and select the “IP NSG Plan of Care Note
(FLOW)” template. This is the “PIE” note template.
Each problem selected should be charted on individually
within the note.
Free text notes can be written by clicking on the “New
Note” button, and selecting the appropriate note type and
then typing into the available note space.
Correcting Charting Errors
1. If you enter the wrong flowsheet data on the right patient’s
chart, go back to the cell and reenter the correct information.
 If a note has been written on the wrong patient, an
addendum should be made on the note indicating that the
note was made in error.
t
today
t–3
3 days ago
m
month
m+6
in 6 months
w
week
w–2
2 weeks ago
y
year
y–1
1 year ago
Remember
 Log out of Epic by selecting the Log Out button at the top of
the screen. Log Out every time you leave the computer to
secure patient information.
HELP
Please call the Help Desk at 6-2160 or (708) 216-2160.
Rev 6/30/2013
Page 42 of 48
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Student Nurse Patient Assignment Sheet
(for use by Instructor)
Student Nurse Patient Assignment Sheet
The Instructor/Student verbally notifies the Nurse responsible for the patient of:
 student assignment to the patient and if the student will be passing patient medications.
2. Once the nurse has been verbally notified, this sheet is to be posted by the Nursing Instructor in the area designated by the Nursing Unit to serve as an
overall view of the student assignments on the nursing unit.
3. This sheet is to be removed by the instructor at the end of the clinical day. Some units may keep form, check with manager/designate
Nursing School:
Day/Date:
Shift:
Instructions:
1.
Instructor Name:
Student Name
1.
Instructor Contact #:
√ if student passing
patient medication
Patient Assignment
If student assigned Off of the Unit, enter their
off-site location
2.
3.
4.
5.
6.
7.
8.
Page 43 of 48
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Nursing Student Course Skills Checklist
(for use by Instructor)
Instructions:
The SON Course Coordinator completes the list of skills for a clinical course and reviews it annually. This
information is shared with each instructor for the course. The list is made available if LUHS requests a copy.
The clinical instructor fills in their name, day, dates and times. Each clinical day the Clinical Instructor posts
the Course Skills Checklist on the assigned unit in the area designated by the unit Manager/designate. The
instructor removes the list at the end of the clinical day
Instructor:
Course:
Clinical Start Date:
Clinical End Date:
Clinical Day(s)
Clinical Start Time:
End Time:
COURSE SKILLS CHECKLIST
List skills nursing students have been trained/educated to perform.
NOTE: skills such as medication administration and starting an IV require
Comment
Instructor supervision
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Page 44 of 48
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Department of Nursing Education
Orientation Checklist – Nursing Student and Instructor
Must be readable
First Name:
Last Name:
School of Nursing Name:
Title (Circle ONE)
Student
Instructor
Student Only: Anticipated Graduation Date:
Month
Year
Instructions: Students and Instructors, are to complete the following requirements PRIOR to starting clinical.
Initial or  in the column provided to indicate that the information has been completed, read and understood.
A. HealthSteam e-Learning Modules
Completed modules assigned in e-learning (i.e. HealthStream) prior to clinical. For modules that are
graded, a minimum score of 80% is required to pass.
EPIC Modules, if required, completed in HealthSteam (If not applicable note with N/A in left column)
B. Read/review information provided for Clinical
All pertinent information provided in the CLINICAL AT LOYOLA UNIVERSITY HEALTH SYSTEM (LUHS)
Guide has been read/reviewed and understood
C. Reports to be on file at SON
1.
2.
Proof of immunity [Rubella, Rubeola/measles, Mumps, Varicella (chickenpox) and Hepatitis B titer as
evidence]
Record of Tdap (tetanus, diphtheria, pertussis) immunization
3.
Background Check
4.
Drug Screen
5.
Current CPR Card
6.
Evidence of initial TB Testing/Screening: QuantiFERON-TB Gold or T-SPOT TB test
7.
8.
Annual Seasonal Flu Vaccination
Color Blindness: Do you have Color Blindness? YES____
NO____
[ Note: a color blindness screening test can be found at http://colorvisiontesting.com/ishihara.htm#demonstration ]
If you answered “yes”, select an answer to the following statement: I have been made aware of associated
safety risks presented by color blindness and of appropriate measures to reduce risk.
True_______
False______ (if false, obtain color blindness testing/screening and
education before starting clinical. Submit documentation)
D. School of Nursing to provide Loyola Nursing Education Department prior to start of clinical
HIPAA Confidentiality Agreement – Student/Instructor turns in signed agreement prior to starting clinical
E. Retain this document in the Student/Instructor Files at the School of Nursing
Turn this document into your School of Nursing. The School of Nursing has information available to submit
if requested by LUMC. For instructor keep until termination. For student keep until graduation
__________
________________
Student Signature
Date
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