The Key
to
Writing Policies and Procedures
Updated: February 2012
Public Health Nursing &
Professional Development Unit
Eunice Inman, RN
Gay Welsh, RN
Pamela Serrell, RN
Ellen Shope, RN
Lynn Conner, RN
Objectives: Part I
 Define
the differences between policies,
procedures and standing orders
 List the content of a policy, procedure and a
standing order
 Define tips on technical writing for policies
and procedures
 Identify resources for writing policies and
procedures
Definition = Policy
A
course of action adopted by and
pursued by an agency that guides and
determines present and future decisions
and actions.
Policies indicate the general course or
direction of an organization within
which the activities of the personnel
must operate.
(The American Correctional
Association)
Definition = Policy
It
is a tool that helps employees attain
agency goals - “what” and “why” of the
goal or intent of the agency.
Definition = Procedures
The
detailed and sequential actions
that must be executed to ensure that a
policy is implemented.
It is the method of performing an
operation or a manner of proceeding on
a course of action.
Definition = Procedures
It
differs from a policy in that it
directs action required to perform a
specific task within the guidelines of
the policy. (The American Correctional
Association)
Describes the “how, who, when or
where” through which policies are
carried out.
Definition = Standing Orders
“Standing
Orders” (SO) are defined as,
“the signed instructions of a physician
which outline the medical assessment,
appropriate testing and treatment that a
clinician may perform or deliver on
behalf of the physician.”
SO serve to standardize the clinical
care practiced by all clinicians.
Definition = Standing Orders
SO
provide the framework to assess
and treat diseases while practicing in
LHDs.
SO allow RNs to determine, based on
parameters identified in the SO whether
a specified condition exists, thus
indicating the need to execute the order.
Definition = Standing Orders
SO
may NOT call for the RN to
discriminate assessment findings beyond
the level of normal vs. abnormal.
Reasons for Policies &
Procedures
 Translate
mission statement into practical
terms
 Shapes the behavior of personnel providing consistency in agency practice
 Protects patients and employees
 Supports accreditation
 Provides legal protection
Contents of Policies
Header contains:
 Title
 Policy Category and/or Number
 Approved By
 Effective Date
 Revised Date
 Affected Program Area(s)
Contents of Policies
 Purpose
Statement = Scope states the “why”
 Definition(s) = clarifies/standardizes terms
 Responsibilities = “who” does it
 Policy/Procedure = “what” shall be done
 Legal Authority = applicable laws/rules
 Reference Policies/Procedures = other
policies/procedures with similar content
Contents of Procedures
Subject
Objective
or purpose of the procedure
Equipment needed
Responsible person
Patient preparation and teaching
Action steps
Contents of Procedures
Documentation
Referral
and follow-up
Additional information
Legal, ethical considerations
Appendices
Note:
Components may vary depending on the type and nature
of the procedure
Tips for Writing P & P
1.Use active voice, present tense
2.Clearly identify the level of priority
3.Use standard word order - subject-verbobject
4.Be consistent
5.Use short words and acronyms
6.Use common words
Tips for Writing P & P
8. Use short sentences and paragraphs
9. Use lists
10. Use few words and avoid redundancies
11. Watch out for problem words and jargon
12. Remember the rules for readability
Template
TITLE:
POLICY NUMBER:
APPROVED BY:
PROGRAM AREA:
EFFECTIVE DATE:
REVISED DATE:
PURPOSE STATEMENT OF POLICY/PROCEDURE
DEFINITIONS
RESPONSIBILITIES
POLICY/PROCEDURE
LEGAL AUTHORITY
REFERENCE POLICIES/PROCEDURES