(a) Written policies and procedures shall be developed and maintained by the person responsible for the service in consultation with other appropriate health professionals and administration. Policies shall be approved by the governing body. Procedures shall be approved by the administration and medical staff where such is appropriate.

(b) The responsibility and the accountability of the respiratory care service to the medical staff and administration shall be defined.

(c) There shall be clear delineation as to who may perform the various procedures, under what circumstances and under whose supervision, with the important undesirable side effects noted if an emergency arises.

(d) All services shall be provided on the order of a person lawfully authorized to give such an order and shall specify the type, frequency of treatment, the dose and type of medication, appropriate dilution ratios and which diagnostic procedures are requested.

(e) A copy of the order shall be available within the respiratory care files in addition to the patient's health record.

(f) Diagnostic studies and treatment modalities shall be recorded in the patient's medical record including the type of diagnostic or therapeutic procedures, the dates and times of their occurrence and their effects including any adverse reactions.

(g) Normal range and acceptable deviations from normal will be clearly delineated. Reactions outside the acceptable usual disease range shall be brought to the attention of the referring physician and the nursing service.

(h) Respiratory care staff shall be involved in orientation and in-service training of hospital employees.

(i) Periodically, an appropriate committee of the medical staff shall evaluate the services provided and make appropriate recommendations to the executive committee of the medical staff and administration.