Healthcare Emergency Preparedness Manual

HEALTHCARE EMERGENCY PREPAREDNESS MANUAL

Facility Name:    Effective Date:

Purpose and Scope

This Emergency Preparedness Manual establishes the policies, procedures, and operational responsibilities for all personnel of the facility to prepare for, respond to, mitigate, and recover from emergencies that affect patient care and facility operations. The scope includes internal facility actions and coordination with external response partners to ensure continuity of care and protection of life and property.

Authority and Compliance

This manual is issued under the authority of the facility executive leadership and is intended to support compliance with applicable federal, state, and local emergency preparedness requirements, including recordkeeping, staff training, and exercise obligations. The policies herein are mandatory for all staff and contractors while on facility premises or performing facility-related duties.

Definitions

Terms used in this manual have the following meanings for consistency of implementation: "Emergency" means any incident that threatens life, safety, property, operations, or public health; "Activation" means initiation of the facility's emergency operations procedures; "Continuity of Care" refers to processes preserving essential clinical services and patient safety during and after an emergency.

Emergency Response Team and Roles

Team roles and primary responsibilities are defined below. Each designated person must acknowledge assigned duties and maintain current contact information.

Activation Criteria and Notification Procedures

The facility shall activate emergency procedures upon identification of an incident that meets any of the following criteria: immediate threat to life or safety, substantial damage to facility infrastructure, loss of essential utilities, or public health emergency. Activation authority is vested in the Emergency Preparedness Coordinator or designee.

Evacuation and Shelter-in-Place Procedures

Evacuation routes, assembly areas, and shelter-in-place instructions are specified by facility zone. The safety of patients, staff, and visitors is the highest priority. Triage of patient movement shall be performed by clinical leads to preserve continuity of care.

Evacuation procedures must include patient prioritization, transport method, medication continuity, and documentation transfer. All staff must follow evacuation checklists and personnel accountability procedures.

Patient Tracking and Continuity of Care

When relocation or sustained incident response is required, patient tracking is mandatory. Complete the following fields for each patient requiring tracking during an emergency.

Date of Birth:    Gender:

Insurance and Billing Information (for tracking)

Medical History and Clinical Needs

Medication and Supply Management

Maintain inventories of essential medications, oxygen, medical supplies, and equipment. Stock rotation, cold-chain management, and contingency resupply agreements are required. Inventory must be accessible during an incident.

Staff Responsibilities, Training and Exercises

All staff must complete initial and annual emergency preparedness training. Training shall include evacuation procedures, patient movement, activation protocols, and privacy protections. The facility will conduct exercises at planned intervals and document outcomes.

Privacy, Records Access, and Documentation

The facility will continue to protect patient privacy and confidentiality to the fullest extent practicable during emergencies. Access to medical records must be limited to authorized personnel whose duties require access. Documentation of care during an emergency must be contemporaneous and integrated into the patient record as soon as operationally feasible.

Staff Acknowledgement: I acknowledge the privacy protections and access restrictions described in this manual and understand that deviations must be documented and justified.

Staff Acknowledgment Confirmed

After-Action Reporting and Continuous Improvement

The facility shall document incidents and exercises in an after-action report that identifies corrective actions, responsible parties, and target completion dates. The Emergency Preparedness Coordinator shall maintain the corrective action log and report status to facility leadership.

Appendix — Key Contacts

The following contacts must be kept current and available to all shift supervisors and the Emergency Response Team.

Certification and Approval

The undersigned certifies that they have reviewed this Emergency Preparedness Manual, that the manual accurately reflects facility emergency policies and procedures, and that the facility will implement and maintain the procedures set forth herein. The certifying official is responsible for ensuring staff training, document distribution, and annual review.

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