Policies Posted for Comment
Draft and recently signed policies are posted here for review and comment by The University of Toledo community for thirty days. Draft policies do not have official status as approved policies until the Approving Officer has signed the policies. Some policies may be signed in advance of the vetting period to comply with the requirement of federal or state laws or regulations or accrediting agencies.
Please direct any comments or questions regarding the policies posted for comment to policies@utoledo.edu or click on the policy number link after "comment on this policy." Please state the name of the policy in the subject line. Comments received on the policy will be forwarded to the policy's responsible agent or agent's designee.
NOTE: The University’s policies ultimately become a part of the Ohio Administrative Code. The Administrative Code is written in lower case. As each UT policy comes due for review, it will be formatted according to the Ohio Legislative Service Commission Drafting Manual. Many words that normally would be capitalized will not be capitalized in the text of the policy. For example – university of Toledo, president of the United States, supreme court, holidays such as Christmas day (Christmas is capitalized but day is not). The Drafting Manual includes many other grammatical guidelines. The header box and the signature box do not need to comply with these rules. Please do not send comments asking to revise capitalization, outline format, grammar, etc.
The following policies have been posted for the 30-day comment period:
UTMC - 26 Policies
Policy Name: 3364-160-SD-144 Psychiatric Advance Directives
Description: (Minor revision) Clarified policy statement and purpose of policy. Removed reference to minors. Updated
definitions. Updated procedure to reflect current Ohio revised code and regulatory
requirements. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-160-SD-144
Policy Name: 3364-100-85-03 Visitation of Patients
Description: (Minor revision) Updated definition of visitation after hours from 8:30 pm to 6:30 am to 8:30 pm to
8:30 am. Added link to reference patient guests code of conduct policy. Other minor
formatting and grammatical changes
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-100-85-03
Policy Name: 3364-133-143 Therapy Management by Pharmacist
Description: (Minor revision) Updated procedure to reflect pharmacist adjustments per protocol. Updated Drug Type
and Intervention with orders. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-133-143
Policy Name: 3364-133-20 Manufacturing and Compounding of Drugs
Description: (Minor revision) Removed reference to the Ohio Administrative Code. Clarification on lot number documentation.
Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-133-20
Policy Name: 3364-135-109 Lost radiation dosimeter
Description: (Minor revision) Updated language from monitor badge to dosimeter throughout document. Clarified
process for identifying radiation exposure for those who lost a dosimeter for a period
for greater than 30 days. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-135-109
Policy Name: 3364-135-111 Radioactive material disposal
Description: (Minor revision) Clarified policy statement. Updated procedure to reflect disposal of contaminated
items, shipping, and documentation requirements. Other minor formatting and grammatical
changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-135-111
Policy Name: 3364-139-1-01 Sterilization Records for Sterile Processing
Description: (Minor revision) Removed Operating Room and Dental Clinic from the title, policy statement, and policy
purpose. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-139-1-01
Policy Name: 3364-139-1-02 Reprocessing and Sterilization of Surgical Instrumentation
Description: (Minor revision) Removed Operating Room and Dental Clinic from the policy statement. Other minor formatting
and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-139-1-02
Policy Name: 3364-171-01-05 Guidelines for emergency situations when recording polysomnograms
Description: (Minor revision) Under General emergency procedure, added medical director or physician on-call as
the contact. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-171-01-05
Policy Name: 3364-171-01-03 Reporting of absences in the Sleep Disorders Center
Description: (Minor revision) Updated purpose of policy and title for Director of Respiratory Care. Other minor
formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-171-01-03
Policy Name: 3364-171-01-06 Inappropriate behavior in the Sleep Lab
Description: (Major revision) Added reference to the weapon policy number. Updated reference to incident reporting,
removed hiring under risk reduction measures and added emergency management section
updates. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-171-01-06
Policy Name: 3364-171-03-02 Home Sleep Apnea Testing (HSAT)
Description: (Minor revision) Updated reference to the Natus MPR language throughout document. Other minor formatting
and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-171-03-02
Policy Name: 3364-171-04-03 Patient management in-lab and Home Sleep Apnea Testing
(HSAT)
Description: (Minor revision) Clarified procedure. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-171-04-03
Policy Name: 3364-171-04-05 Scheduling of Sleep Studies
Description: (Major revision) Updated procedure to reflect current levels of no show/late cancellations, patients
requiring a caregiver and documentation. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-171-04-05
Policy Name: 3364-171-03-07 Split-night studies
Description: (Minor revision) Clarified acronyms throughout document. Clarified that the medical director or sleep
specialty assigned to the study shall be contacted in case of emergency. Other minor
formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-171-03-07
Policy Name: 3364-171-07-02 Clinical guidelines for manual titration of positive airway pressure
using bi-level volume assured pressure support
Description: (Minor revision) Removed reference to Res Med Sleep Lab Titration Guide 2017. Added reference to
Procedure: Volume-assured pressure support (VAPS) titration procedure.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-171-07-02
Policy Name: 3364-171-07-04 Clinical guidelines for manual titration of positive airway
pressure using bilevel
Description: (Minor revision) Removed algorithm and journal reference. Added reference to procedure: Clinical Guidelines
for Manual Titration of Positive Airway Pressure using Bilevel. Other minor formatting
and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-171-07-04
Policy Name: 3364-171-07-01 Adaptive Servo ventilation (ASV) Titration Procedure
Description: (Major revision) Clarified and updated charting procedure. Added charting interventions, post as
a progress note in the electronic medical record, and updated charting of education.
Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-171-07-01
Policy Name: 3364-109-EQP-802 Linen Processes, which includes contracted linen services providers
Description: (Minor revision) Clarified linen processes and updated references. Other minor formatting and grammatical
changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-109-EQP-802
Policy Name: 3364-109-EQP-307 Disinfecting procedure for mobile tablets
Description: (Minor revision) Clarified procedure and updated references. Other minor formatting and grammatical
changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-109-EQP-307
Policy Name: 3364-138-02 Status epilepticus
Description: (Minor revision) Changed procedure for Detection and reporting. EEG tracings the reveal continuous
or periodic epileptiform discharges that meet the criteria established for status
epilepticus, shall be reported to the EEG reader or Neurologist immediately. Removed
EEG Tech notification for EEG tracings. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-138-02
Policy Name: 3364-138-11 EEG monitoring during Wada
Description: (Major revision) Clarified procedure to add to neurophysiologist will perform memory tasks in addition
to neuropsychologist. Updated information for patients receiving injections. Clarified
documentation and adverse event notification. Other minor formatting and grammatical
changes.
Scope: University of Toledo Medical Center
Comment Period: June 18, 2026 - July 18, 2026
Comment on this policy: 3364-138-11
Policy Name: 3364-100-53-27 Surgical Services
Description: (Minor revision) Updated emergent case time to include OR is staffed and available within 15 minutes
of notification. Surgery hours of operation, staff, anesthesia, and supplies are
in house 24/7. For on-call response notification, added this notification and hence
response are automatic upon first team staffing OR case. This permits 15-minute availability
for subsequent class X cases. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: May 29, 2026 - June 29, 2026
Comment on this policy: 3364-100-53-27
Policy Name: 3364-133-40 Home Medications
Description: (Minor revision) Clarified policy statement and purpose of policy. Updated procedure to clarify inpatient
use of home medications. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: May 29, 2026 - June 29, 2026
Comment on this policy: 3364-133-40
Policy Name: 3364-133-123 Pharmacist Charting
Description: (Minor revision) Clarified and updated charting procedure. Added charting interventions, post as
a progress note in the electronic medical record, and updated charting of education.
Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: May 29, 2026 - June 29, 2026
Comment on this policy: 3364-133-123