nursing policies and procedures manual

%%EOF Policies and procedures are an incredibly important part of making sure staff know how to care for patients and how to carry out tasks with confidence. By downloading and purchasing a! Policy and Procedure Review It cannot be overstated that policies and procedures must be constantly reviewed and updated. 6. Transparency and honesty is of utmost importance when it comes to our industry. This manual provides direction and guidance to regional health authorities. Policy and Procedure Manual review is a standing agenda item for the first Simulation Committee Meeting of each academic year. (“Electronic Publication”). Lippincott® Procedures is your online source for instant, evidence-based procedure guidance at the point of care. 3035 0 obj <> endobj NC Department of Health and Human Services 2001 Mail Service Center Raleigh, NC 27699-2001 919-855-4800 The policy (Policy #5) can also be found under Policies (A-Z index) on the GSU webpages. Thank you to the following professionals for their tireless effort in revising this and past editions: The Policy and Procedure Manual is reviewed annually by the Simulation Committee for necessary revisions and updates. All current subscriptions will be honored. The Office of Child Support is in the process of moving all policy from the policy manuals and Action Transmittals (ATs) to the new Michigan IV-D Child Support Manual. The documents are intended to provide guidance to nursing staff in the delivery of safe and effective patient care. 475 KB. A-1: Policy on Policies. Staffing & Staff Structure . Long Term Care Policy and Procedure Manual, Table of Contents - TJC Standards and CMS Regulations, 1001 - Emergency Management Program (EMP), 1002 - Communication Plan During an Emergency/Disaster, 1006 - Emergency Management Training Record Form, 2003 - Nursing Staff Information Daily Posting, 2004 - Staff Qualifications and Competency, 2005 - Non-Employee Qualification and Competency Verification, 2006 - Use of Supplemental Nurse Staffing Agencies, 2007 - Contracted Staff Compliance Checklist, 2011 - Licensure, Certification and Registration Verification and Control Systems, 2013 - Pre-Employment Physical Examination, 2014 - Health Questionnaire for Positive Tuberculosis Skin Test Reactions, 2016 - Measles, Rubella and Varicella Disease Screening - Staff, 2019 - New Employee Orientation Checklist - Clinical Staff, 2025 - Departmental Inservice Record Form, 2027 - Continuing Education/Inservice Program Form, 2028 - Nursing Education Record Form - Sample, 2030 - Psychotropic Medications - Staff Education, 2032 - Fire Safety - Staff Responsibilities for General Fire Prevention, 2034 - Hazardous Materials and Waste - Training, 2035 - How to Read Safety Data Sheets (SDS), 2036 - Hazard Communication Employee Information and Training Schedule/Log, 2037 - New Employee Chemical Inservice Sample Memo, 2039 - Hazard Communication Employee Training Record Form, 2040 - Medical Equipment User/Maintainer Orientation/Education, 2041 - Employee Equipment Training and Competency Form, 2042 - Medical Equipment User/Maintainer Training Log, 2045 - Body Mechanics - Staff Education Handout, 2046 - Workplace Violence Prevention Training Outline, 2049 - Staff Safety Education Report Form, 2051 - Quarterly Report to Governing Body - Personnel Evaluations, 2052 - Attendance, Scheduling Nursing Services Staff Guidelines/Restrictions, 2101 - Verification of LIPs' Competence to Provide Care, Treatment and Services, 2102 - Privileging of Licensed Independent Practitioners New to the Organization, 2103 - Allowing LIPs to Provide Care, Treatment and Services on a Temporary Basis, 2105 - Licensed Independent Practitioner Orientation, 2201 - Position Description/Performance Evaluation - Long Term Care Director of Nursing, 2202 - Performance Evaluation - Population-Specific/Age-Related Competency - Long Term Care Director of Nursing, 2203 - Annual Competency Clinical Skills Assessment - Long Term Care Director of Nursing, 2204 - Position Description/Performance Evaluation - Long Term Care Nurse Manager, 2205 - Performance Evaluation - Population-Specific/Age-Related Competency - Long Term Care Nurse Manager, 2206 - Annual Competency Clinical Skills Assessment - Long Term Care Nurse Manager, 2207 - Position Description/Performance Evaluation - Long Term Care Registered Nurse, 2208 - Performance Evaluation - Population-Specific/Age-Related Competency - Long Term Care Registered Nurse, 2209 - Annual Competency Clinical Skills Assessment - Long Term Care Registered Nurse, 2210 - Position Description/Performance Evaluation - Long Term Care LPN/LVN, 2211 - Performance Evaluation - Population-Specific/Age-Related Competency - Long Term Care LPN/LVN, 2212 - Annual Competency Clinical Skills Assessment - Long Term Care LPN/LVN, 2213 - Position Description/Performance Evaluation - LTC Certified Nursing Assistant Coordinator, 2214 - Performance Evaluation - Population-Specific/Age-Related Competency - LTC Certified Nursing Assistant Coordinator, 2215 - Annual Competency Clinical Skills Assessment - LTC Certified Nursing Assistant Coordinator, 2216 - Position Description/Performance Evaluation - LTC Lead Certified Nursing Assistant, 2217 - Performance Evaluation - Population-Specific/Age-Related Competency - LTC Lead Certified Nursing Assistant, 2218 - Annual Competency Clinical Skills Assessment - LTC Lead Certified Nursing Assistant, 2219 - Position Description/Performance Evaluation - LTC Certified Nursing Assistant (CNA), 2220 - Performance Evaluation - Population-Specific/Age-Related Competency - LTC Certified Nursing Assistant (CNA), 2221 - Annual Competency Clinical Skills Assessment - LTC Certified Nursing Assistant (CNA), 2222 - Position Description/Performance Evaluation - Long Term Care CNA Activity Assistant, 2223 - Performance Evaluation - Population-Specific/Age-Related Competency - Long Term Care CNA Activity Assistant, 2224 - Annual Competency Clinical Skills Assessment - Long Term Care CNA Activity Assistant, 2225 - Position Description/Performance Evaluation - LTC Admissions Coordinator, 2226 - Performance Evaluation - Population-Specific/Age-Related Competency - LTC Admissions Coordinator, 2227 - Annual Competency Clinical Skills Assessment - LTC Admissions Coordinator, 2228 - Position Description/Performance Evaluation - LTC Social Worker, 2229 - Performance Evaluation - Population-Specific/Age-Related Competency - LTC Social Worker, 2230 - Annual Competency Clinical Skills Assessment - LTC Social Worker, 2231 - Position Description/Performance Evaluation - LTC Unit Secretary, 2232 - Performance Evaluation - Population-Specific/Age-Related Competency - LTC Unit Secretary, 2233 - Annual Competency Skills Assessment - LTC Unit Secretary, 2234 - Annual Competency - Joint Commission National Patient Safety Goals, 3001 - Infection Prevention and Control Program, 3002 - Infection Prevention and Control Committee - Organization and Function, 3003 - Infection Prevention and Control Committee - Authority, 3004 - Position Description/Performance Evaluation - Infection Preventionist, 3005 - Performance Evaluation - Population-Specific/Age-Related Competency - Infection Preventionist, 3006 - Annual Competency Clinical Skills Assessment - Infection Preventionist, 3008 - Infection Prevention and Control Plan, 3011 - Infection Prevention and Control Incident Tracking, 3012 - National Notifiable Infectious Conditions, 3014 - Infection Control - Infection Review Report Form, 3015 - Department-Specific Infection Prevention and Control Responsibilities, 3018 - Hand Hygiene/Glove Use Observation Form, 3019 - Respiratory Hygiene/Cough Etiquette in Healthcare Settings, 3020 - Personal Protective Equipment - Use of, 3021 - Personal Protective Equipment - Training, 3022 - Order for Putting On and Removing PPE, 3024 - Transmission-Based Precautions (Isolation Precautions), 3025 - Response to an Influx of Infectious Residents, 3026 - Third-Party Reprocessing of Single-Use Devices for Long Term Care Facilities, 3027 - Infection Prevention and Control - Central Service, 3028 - Infection Prevention and Control - Laundry, 3030 - Infection Prevention and Control - Environmental Services, 3031 - Infection Prevention and Control - Nutritional Services, 3105 - Accidental Blood or Body Fluid Exposure/Contamination - Management of, 3106 - Accidental Exposure to Blood/Body Fluids - Emergency Department Medical Evaluation, 3107 - Accidental Exposure to Blood/Body Fluids - Employee Follow-Up Instruction Sheet, 3202 - Workplace Injury, Illness or Fatality Reporting, 3203 - Employee Reporting and Work Restrictions Due to Exposure to Communicable Diseases, 3204 - Influenza Vaccination Program for Healthcare Staff, 3206 - Informed Consent for Hepatitis B Vaccine Form, 3207 - Hepatitis B Vaccine Declination Form, 3210 - Health Questionnaire for Positive Tuberculosis Skin Test Reactions, 3211 - Baseline and Follow-up Testing for M. Tuberculosis Infection, 4002 - Healthcare Confidentiality Principles, 4003 - Organizational Assessment of Information Management Needs Form, 4004 - Computer Interruption/Malfunction/Destruction Plan, 4005 - Confidentiality of Information - General Issues, 4006 - Confidentiality of Information - Electronic Health Records, 4009 - Administrative Safeguards - Workforce Authorization/Supervision, 4010 - Administrative Safeguards - Workforce Clearance and Access Authorization, 4011 - Administrative Safeguards - Workforce Termination, 4012 - Resident Access to Medical Records, 4014 - Release of Resident Information Consent Form, 4016 - Uses and Disclosures of Protected Health Information - General Rules, 4017 - Accounting of Disclosures of Protected Health Information, 4018 - Amendment of Protected Health Information, 4019 - Medical Records Destroyed by Man-Made or Natural Disaster, 4020 - Contingency Plan for Water Damaged Medical Records, 4021 - Health Information Management Department Fire Plan, 4022 - Intentional Destruction of Medical Records, 4024 - Documentation and the Use of Abbreviations, Acronyms and Symbols, 4025 - Unacceptable Abbreviation and Symbol List, 4026 - Retrieval of Information/Disease and Operation Indices, 5005 - Director of Nursing Responsibilities, 5006 - Mission, Vision, Values and Goals Statement, 5008 - Plan for the Provision of Resident Care and Services, 5009 - Staff Retention and Recruitment Plan, 5011 - Communication Process - Staff, Residents and Community, 5013 - Examples of Survey Tools to Survey a Culture of Safety and Quality, 5015 - Disruptive and Inappropriate Behavior, 5016 - Disruptive Staff Member Incident Report Form - Sample, 5018 - Departmental/Unit Staff Meeting Format, 5020 - Facility Annual Review Class Agenda, 5022 - Post Test - Facility Annual Review, 5025 - Compliance Plan for Long Term Care, 5026 - The OIG Work Plan - 2017 - Nursing Homes and Hospice, 5027 - Reporting Requirements for Crimes Committed in the Facility, 5030 - Purchases, Capital Expenditures - Equipment, Renovation, Supplies, 5033 - Governing Body Financial Meeting Agenda, 5034 - Facility Program, Service, Site, Department Leadership, 5035 - Development of Departmental Policies and Procedures, 5036 - Development of Interdepartmental Policies and Procedures, 5039 - Sample Conflict of Interest Disclosure Letter, 5040 - Conflict Management Among Leadership Groups, 5043 - Financial Incentives/Clinical Decision Making, 5046 - Staff Rights and Ethical Dilemmas in Resident Care, 5049 - Community Needs Assessment Survey Tool/Questionnaire, 5052 - Oversight of Contractual Agreements, 5054 - Contracted Service Provider Evaluation Form, 5055A - Provision of Dialysis Services in Long Term Care, 5056 - Outside Reference Laboratory Authorization, 5060 - Joint Commission National Patient Safety Goals, 5064 - Failure Mode and Effects Analysis Form, 5068 - Organizational Leadership (Governing Body) Self-Assessment Form, 5069 - Governing Body Meeting Quarterly Agenda, 6010 - Facility's List of High-Risk/High Alert Medications, 6011 - Look-Alike, Sound-Alike Medication Management, 6012 - Monthly Ordering of Medications (Provider Pharmacy), 6013 - Ordering and Receiving Medications from an Alternate Pharmacy, 6014 - Notice of Intent to Purchase Medications from an Alternate Pharmacy Provider Form - Sample, 6015 - Drug Acquisition/Storage/Inspection/Dispensing, 6016 - Automated Dispensing Machines - Access to, 6017 - Automated Dispensing Machines - Stock Medication, 6018 - Automated Dispensing Machines - Controlled Substances, 6022 - Disposal of Controlled Substance Patches, 6023 - Concentrated Electrolyte Solutions and Other Drug Concentrations, 6024 - Emergency Medications and Antibiotics, 6026 - Resident's Own Medications (Storage and Destruction), 6028 - Prescribing/Ordering - General Practices, 6029 - Telephone, Verbal and Written Orders for Medication, 6031 - Stop-Order Policy Letter to Physicians, 6037 - Residents' Use of Herbals and "Natural" Remedies, 6038 - Influenza and Pneumococcal Vaccine Standing Orders, 6039 - Vaccine Information Statements (VISs) - Use of, 6046 - Automated Dispensing Machines - Pharmacist Order Verification and Drug Distribution, 6047 - Automated Dispensing Machines - Emergency/STAT Medication Orders, 6050 - Medications Dispensed by Physician, 6051 - Obtaining Medications (No On-Site Pharmacy), 6057 - Automated Dispensing Machines - Removing Medications, 6062 - Single-Use/Single-Dose Vials - Use, 6064 - Oral Unit Dose and Pre-Mixed Infusion Products - Anticoagulation Therapy Management Program, 6065 - Warfarin Therapy - International Normalized Ratio (INR), 6066 - Heparin - Independent Double Check, 6067 - Heparin IV Administration - Programmable Pumps, 6067A - Direct Oral Anticoagulants - Considerations for Use, 6069 - Food-Drug Interaction Notification and Counseling, 6070 - Food and Drug Interactions Guide - Resident Brochure, 6071 - Resident Education - Anticoagulation Therapy, 6073 - Self-Administration of Medications by Residents, 6074 - Antimicrobial Stewardship Program Implementation Plan - Nursing Homes, 6076 - Antibiotic Stewardship Program Education Plan, 6076B - Concise Antibiogram Toolkit - Comprehensive Antibiogram Template, 6078 - Assessment for Self-Administration of Medications Form, 6081 - Consent for Use of Investigational Drug - Sample Form, 6082 - Investigational Drug Information Record, 6083 - Monitoring Effects of Medications on Residents, 6087 - Performance Improvement Analysis - Medication Incident Form, 6089 - Potential Adverse Drug Reaction Form, 6090 - Adverse Drug Reaction Reporting Form (Internal), 6091 - Facility Adverse Drug Reaction Report Form, 7001 - Organizational Performance Improvement Plan, 7002 - Performance Improvement Monitoring and Evaluation Plan (Blank), 7003 - Performance Improvement Trending Sheet (Blank), 7004 - Performance Improvement Outcome Evaluation (Blank), 7005 - Performance Improvement Volume Measures/Statistics (Blank), 7006 - Facilitywide Performance and Outcome Measures - Examples, 7007 - Reporting of Potentially Compensable Events, 7010 - Resident Satisfaction Questionnaire, 7011 - Resident Satisfaction Questionnaire - Physical Therapy Services, 7012 - Resident Satisfaction Survey Results Form, 7013 - Resident Satisfaction Survey - Individual Comment Report Form, 7014 - Resident Satisfaction Questionnaire Trending Sheet, 7015 - Resident's Negative Perceptions Identification on the Resident Satisfaction Questionnaires Form, 7017 - Performance Improvement Project Priority Determination Form, 7020 - Continuous Quality Improvement Team Activity Report Form, 7021 - LTC Activities Department PI Monitoring and Evaluation Plan, 7022 - LTC Activities Department PI Trending Sheet, 7023 - LTC Activities Department PI Outcome Evaluation, 7024 - LTC Environmental Services PI Monitoring and Evaluation Plan, 7025 - LTC Environmental Services PI Trending Sheet, 7026 - LTC Environmental Services PI Outcome Evaluation, 7027 - LTC Nursing PI Monitoring and Evaluation Plan, 7030 - LTC Nutritional Services PI Monitoring and Evaluation Plan, 7031 - LTC Nutritional Services PI Trending Sheet, 7032 - LTC Nutritional Services PI Outcome Evaluation, 7033 - LTC Pharmacy PI Monitoring and Evaluation Plan, 7035 - LTC Pharmacy PI Outcome Evaluation, 7036 - LTC Social Service PI Monitoring and Evaluation Plan, 7037 - LTC Social Service PI Trending Sheet, 7038 - LTC Social Service PI Outcome Evaluation, 7039 - LTC Staff Development PI Monitoring and Evaluation Plan, 7040 - LTC Staff Development PI Trending Sheet, 7041 - LTC Staff Development PI Outcome Evaluation, 7042 - Restraint Monitoring - Facilitywide PI Trending Sheet, 7043 - Reduce the Risk of Influenza and Pneumococcal Disease - PI Outcome Monitoring, 7044 - PI Outcome Monitoring - Prevent Healthcare-Associated Pressure Ulcers (Decubitus Ulcers), 7045 - PI Outcome Monitoring - Reduce the Risk of Patient/Resident Harm Resulting From Falls, 7047 - CQI Storyboard - Management of MRSA, 7048 - Staffing Effectiveness - Long Term Care, 7050 - Narrative Notification Summary Report Form, 7051 - Physician Reappointment Performance Improvement Profile Form, 7052 - Performance Improvement Governing Body Quarterly Summary Form, 7053 - Performance Improvement Governing Body Quarterly Report Form, 7054 - Performance Improvement Program Annual Evaluation Form, 7055 - Performance Improvement Committee Annual Program and Leadership Evaluation Form, 7056 - Incident Reporting Staff Questionnaire Form, 8003 - Admission Criteria - Physician's Responsibility, 8008 - Physician Visits and Medical Orders, 8009 - Physician Delegation of Tasks in SNFs, 8011 - Comprehensive Assessment and Reassessment, 8013 - Certification of the Comprehensive Assessment, 8015 - Resident Medication Information and Reconciliation, 8016 - Resident Medication Information and Reconciliation Form, 8021 - Pain Assessment, Reassessment and Management, 8022 - Pain Scale - Behavioral-Physiological Scale for Nonverbal or Preverbal Residents, 8025 - Assessment of Adult Patient/Resident at Risk for Falls Form, 8027 - Latex Sensitive Resident - Care of, 8031 - Interdisciplinary Team Plan of Care, 8105 - Blood/Blood Components - Transfusion, 8107 - Blood/Blood Components - Transfusion Reactions, 8112 - Emergency Crash Cart Security and Accountability, 8113 - Catheter-Associated Urinary Tract Infection Prevention Program, 8114 - Indwelling Urinary Catheter Insertion and Maintenance - Female Resident, 8115 - Indwelling Urinary Catheter Insertion and Maintenance - Male Resident, 8116 - Residents with Indwelling Catheters, 8117 - Central Venous Lines and PICC Lines Bundle - Insertion of, 8118 - Central Venous Catheter and PICC Line Time Out Checklist, 8119 - What You Need to Know About Central Line Infections (CLI), 8120 - Clinical Alarms - Maintenance and Use of, 8122 - Coordination of Care, Treatment and Services, 8127 - Enteral Feeding via Nasogastric or Gastrostomy Tube, 8140 - Influenza Outbreaks - Management of, 8141 - Invasive Procedure Site Identification (Outside of the OR), 8146 - Supplemental Nutritional Support and Snacks, 8152 - Food Supply - General Requirements, 8155 - Refrigerator/Freezer Temperature Check Sheet, 8157 - Methicillin Resistant Staphylococcus Aureus (MRSA) - Management of, 8159 - Clostridium difficile (C. difficile), 8161 - Norovirus Outbreak - Cleaning and Disinfection, 8162 - Notification of Change in Resident's Condition, 8163 - Notification of the Pastoral Care Department, 8167 - Oxygen Administration per Nasal Cannula, 8168 - Oxygen Administration per Partial Rebreathing Mask, 8169 - Oxygen Administration per Simple Mask, 8170 - Oxygen Administration per Venturi Mask, 8171 - Pet Therapy in Long Term Care Facilities, 8173 - Physician Order Review - RN Verification, 8176 - Pressure Ulcer (Injury) Prevention Program, 8177 - Photographing Pressure Ulcers/Suspected Physical Abuse, 8179 - Physical Therapy - Resident Referrals, 8180 - Physical Therapy - Evaluation/Treatment Time Frame, 8183 - Discontinuance of Physical Therapy Services, 8185 - Alternatives to Physical or Chemical Restraints, 8187 - Indications for Chemical Restraints, 8189 - Restraint Use Competency Checklist - Restraint for Management of Nonviolent, Non-Self Destructive Behavior, 8190 - Use of Restraint and Seclusion Application/Removal Competency Checklist - Restraint for Management of Violent or Self-Destructive Behavior, 8192 - Resident Identification for Clinical Care and Treatment, 8197 - Resident Transfer Protocol - Safety Techniques in Transfer, 8204 - Ventilator Maintenance/Monitoring - Recommended Parameters, 8304 - Resident Education - Discharge Medication, 8305 - Resident Education - Medications Education, 8306 - Resident Education - Medical Equipment, 8307 - Resident Education - Modified Diets, 8308 - Resident and Family Education Guideline - Pain Management, 8312 - Education for Long-Term Pediatric Residents, 8405 - Resident Notice of Transfer or Discharge, 8406 - Transfer/Discharge Resident Notification Letter, 8409 - Transfer Agreement Between Hospital and Skilled Nursing Facility Form, 8410 - Transfers Between Facility and Hospital, 8411 - Transfer of Critically Ill Residents, 8412 - Transfer of Mentally/Emotionally Disturbed or Difficult to Manage Residents, 9004 - Medical Record - Physician Responsibilities, 9005 - Medical Record Documentation - Activities Program, 9006 - Medical Record Documentation - Nutritional Services, 9007 - Medical Record Documentation - Nursing Care, 9008 - Medical Record Documentation - Medical Treatment and Care, 9009 - Medical Record Documentation - Rehabilitation Services, 9010 - Medical Record Documentation - Social Service, 9011 - Medical Record Documentation - Resident/Family Education, 9012 - Medical Record Documentation - Care of Residents by Off-Site Sources, 9013 - Medical Record Documentation - Medications, 9014 - Medical Record Documentation - Resident Discharge/Transfer, 9015 - Verbal and Written Orders - General, 9016 - Accessibility of the Medical Record, 9018 - Legibility of Medical Record Documentation, 9021 - Medical Record Review Tool - Sample Form, 10001 - Resident Rights Given to Resident/Family at Admission, 10005A - General Considerations for Arbitration Agreements, 10006 - Medicare and Medicaid Benefits Notice, 10010 - Resident Rights to Privacy and Confidentiality, 10011 - Residents Returning to the Facility, 10014 - Interpreter Services and Protected Health Information, 10016 - Social/Spiritual/Community Activities, 10017 - Planning and Implementation of Care - Resident Communication, 10019 - Informed Consent Form for Restraints - Sample, 10020 - Blood/Blood Component - Informed Consent, 10021 - Recordings, Films or Other Images of Residents, 10022 - Authorization and Consent Form - Recordings, Films or Other Images, and Publication, 10023 - Clinical Trials/Research Projects - Conduct of, 10024 - Waiver of Authorization - Research Project, 10025 - Use of Investigational Drug/Treatment, 10026 - Authorization for the Use and Disclosure of PHI for Research Purposes, 10029 - Advance Directives - Statement of Limitation, 10030 - Withholding or Withdrawal of Life-Sustaining Measures, 10031 - Sample Directives for Resuscitation, 10032 - Clinical Determination of Withholding of Life-Sustaining Treatment, 10034 - Requirements for Management of Organ and Tissue Donation, 10035 - Child, Adult, Disabled Person or Elderly Abuse - Recognition and Reporting, 10036 - Recognizing and Reporting Elder Abuse/Neglect - Criteria, 10040 - Email, Video Communication, Internet Use, 10041 - Resident's Citizenship Privileges, 10042 - Selection of Medical, Dental and LIP Care Providers, 10043 - Resident Communication with Physicians, 10045 - Dental Services - Skilled Nursing Facility, 10046 - Dental Services - Nursing Facilities, 10047 - Resident Right to manage Financial Affairs, 10049 - Statement of Financial Condition Form, 10051 - Conveyance Upon Discharge, Eviction or Death, 10054 - Resident Complaint and Grievance Process, 10055 - Referrals to the Public Guardian's Office - Persons with Grave Disability, 10056 - Probate Conservatorship Guidelines, 10057 - Resident Advocacy Group List for Residents and Families, 10063 - Convening of the Ethics Committee, 11003 - Blood Glucose Monitoring Competency Checklist. 6 II, statutes, and accreditation requirements ( e.g standards, standard work medical. 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