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How to Set Your Medical Practice Up for Success - Part 3: Documentation

Kevin Webber - Mar 9, 2018 4:35:54 PM

Filing-Cabinet-Medical-DocumentationProper documentation is a critical component for quality healthcare delivery. It is also critical for medical waste management and compliance. Most medical waste generators understand the importance of properly disposing of hazardous material, but they may not realize that documentation is key to successful medical waste management.

You can avoid fines and penalties by maintaining the proper documentation. We’ve compiled a list of important documents you'll need to help set your practice up for success.

What documents do you need?

Written Medical Waste Management Plan

Your practice is required to have a written plan for managing your medical waste. The Alabama Department of Environmental Management (ADEM) requires a plan that includes the names and contact information for the managing authority in your medical facility, as well as relevant roles for all waste management business associates. Also included is information on the type of waste your facility generates and how often it is removed, and how that waste complies with the segregation, packaging, and disposal regulations.


Even though a medical waste provider is handling your facility’s hazardous medical waste, remember that you are still responsible for that waste until after its final disposal. With that in mind, you are required to make sure your waste provider gives you written certification stating that all handling and treatment requirements have been satisfied. This documentation should include both a signed manifest upon waste pickup and a certificate of destruction after the medical waste is rendered non-infectious or destroyed and disposed.

Waste Provider Permits

By verifying that you medical waste provider maintains all relevant permits, you can reduce the chance of penalties and fines. Improper transporting and treatment of your regulated medical waste can be avoided if you know your provider has these permits: State Medical Waste Transportation Permit, State Hazardous Waste Transportation Permit, Department of Transportation Permit, Notification of Regulated Waste Activity, Pharmaceutical Waste Permit, and Medical Waste Treatment Permit. Your chosen partner can provide copies of these permits to keep on file. Here is some more information you should know about permits for transporting regulated medical waste.


Training information, including the steps your medical facility takes to reduce employee risk should also be documented in your medical waste management plan. In addition, you are required to keep current Bloodborne Pathogens (BBP) training certificates for all clinical employees. Copies of all other current employe training certificates should also be kept on file.

Exposure Control Plan

This plan is a central component of OSHA’s Bloodborne Pathogens Standard and its purpose is to eliminate or minimize occupational exposures. Your plan should include a list of job classifications in which all workers have occupational exposure and a list in which some workers have exposure, along with a list of the tasks performed by the workers that result in their exposure. The plan must be updated annually to reflect any changes in positions, tasks, and procedures that affect occupational exposure. Other required documentation covers the implementation of work practice controls and other measures — OSHA has a handy exposure control plan template.

Fire Prevention Plan

This plan details the measures you take to prevent a fire from occurring in your workplace. It describes any fuel sources at your facility that could either initiate or contribute to the spread of a fire and the procedures you take to control those. It also details the systems you have in place (fixed fire extinguishing and alarm systems) to control a fire and regular maintenance procedures for those safeguards. The names and job titles of employees responsible for those procedures are also required.

Hazard Communication Plan

OSHA requires employers that have hazardous chemicals in their workplace to implement a hazard communication program. The program includes hazardous chemical container labeling, chemical safety data sheets (SDS) for hazardous chemicals, and training for workers. The written plan describes how your facility will meet the requirements in each of these areas and keeps a list of known hazardous chemicals that are present in your workplace. emer

Emergency Action Plan

The Emergency Action Plan (EAP) is another OSHA standards requirement. Its purpose is to organize and facilitate employer and employee actions during a workplace emergency. During an emergency, everyone needs to understand their roles and responsibilities. Your plan will describe how employees will respond to different types of emergencies, taking into account your facility layout and emergency systems. Also, your employees need to know the proper way to report an emergency — both internally and to the proper authorities.


Proper documentation helps ensure that you have the necessary procedures in place for your facility and that you stay compliant. It also ensures that your waste management provider is following the necessary steps to maintain compliance. Initially, the documentation may seem like a lot of work. However, once you have everything in place, your practice will be set up for success.

Download medical waste handling guide (ebook)

Topics: Compliance

Kevin Webber

Kevin Webber

Kevin Webber is a partner at TriHaz Solutions and actively involved in the day-to-day business from a strategic and operational standpoint. He has a successful background in business/investment management and entrepreneurship, including recognition by Inc. Magazine’s 5000 list of fastest-growing private companies.

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