Guidelines for Developing Policies and Procedures

The performance of clinical procedures is “governed” by written policies. Policies outline the steps you should follow in a particular situation and usually provide an explanation of why it is important to proceed in the outlined manner.

The format of policies and procedures is usually a policy statement which states the agency’s belief regarding a specific issue and a procedure portion which states what action is to be taken, who is responsible, and what documentation is necessary. Procedures should be written to provide for discretions to be exercised by nurses as they consider the facts of specific situations and are not absolute rules.

  1. Write the policy as clear as possible. Use consistent terminology and define terms to ensure clarity. i.e., is a nurse an RN, LPN or both.
  2. Base the policy and procedure on current and accurate knowledge and national standards.
  3. Avoid using the words “responsible for” as that may impose strict or automatic liability even when it is appropriate to delegate a task to another. Better language is: “The RN or a designee...” This permits the RN to delegate a task to another individual.
  4. Review each policy periodically and ensure that the written statement is consistent with the current practice within your agency. Policies should be dated to reflect when they became effective and when any revisions were made. Outdated policies should be maintained for the same period of time in which other medical records are kept for purposes of potential legal actions.
  5. Make it clear that the written policy cannot be overridden by verbal changes. All changes should be in writing and approved by the appropriate people.
  6. Make sure all involved staff are advised of policy changes, and review all policies on a routine basis.
  7. Make sure policies are available to all staff at all times.

Cummings, Constance. Keeping Written Policies Up-to-Date. Maginnis & Associates Publication.

Feutz-Harter, Sheryl. (1993). Nursing and The Law. Professional Education Systems, Inc.

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