| The following patient treatment and care documents shall be written, distributed, and monitored for quality: |
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| A. Resuscitation policy; |
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| B. Transfusion and Massive Transfusion policy; |
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| C. Infection control plan(can utilize hospital plan); |
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| D. Trauma team activation policy; |
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| E. Physician call schedule; |
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| F. Subspecialty notification policy; |
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| G. Inter-hospital transfer policy; |
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| H. A policy providing that trauma patients may not be admitted or transferred by a primary care physician without the knowledge and consent of the trauma service, with monitoring of adherence by the QM program; |
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| I. Helicopter safety policy; and |
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| J. Organ procurement policy. |
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E |