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 F Define the differences between policies, procedures and standing orders F List the content of a policy, procedure and a standing order F Define tips on technical writing for policies and procedures F Identify resources for writing policies and procedures

Definition = Policy F A course of action adopted by and pursued by an agency that guides and determines present and future decisions and actions. F 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 F It is a tool that helps employees attain agency goals - “what” and “why” of the goal or intent of the agency.

Definition = Procedures F The detailed and sequential actions that must be executed to ensure that a policy is implemented. F It is the method of performing an operation or a manner of proceeding on a course of action.

Definition = Procedures F 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) F Describes the “how, who, when or where” through which policies are carried out.

Definition = Standing Orders F “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.” F SO serve to standardize the clinical care practiced by all clinicians.

Definition = Standing Orders F SO provide the framework to assess and treat diseases while practicing in LHDs. F 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 F SO may NOT call for the RN to discriminate assessment findings beyond the level of normal vs. abnormal.

Reasons for Policies & Procedures F Translate mission statement into practical terms F Shapes the behavior of personnel - providing consistency in agency practice F Protects patients and employees F Supports accreditation F Provides legal protection

Contents of Policies Header contains: F Title F Policy Category and/or Number F Approved By F Effective Date F Revised Date F Affected Program Area(s)

Contents of Policies F Purpose Statement = Scope states the “why” F Definition(s) = clarifies/standardizes terms F Responsibilities = “who” does it F Policy/Procedure = “what” shall be done F Legal Authority = applicable laws/rules F Reference Policies/Procedures = other policies/procedures with similar content

Contents of Procedures F Subject F Objective or purpose of the procedure F Equipment needed F Responsible person F Patient preparation and teaching F Action steps

Contents of Procedures F Documentation F Referral and follow-up F Additional information F Legal, ethical considerations F Appendices F 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-verb- object 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

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