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Policy and Procedure Manual in Practice Management

The office policy and procedure manual serves as a resource to optimize the quality of care and operations of the practice. It should educate your staff on standard office proceedings while allowing some flexibility if strict adherence would adversely interfere with patient relations. Policies and procedures must be reasonable and easy for the staff to follow.

Ensure your policies and procedures reflect current regulations. Policies that do not comply with changes in state or federal laws or are simply outdated may expose the practice to unnecessary risk. When writing office policies and procedures, consider what is required by law or regulation because exceeding it can be a source of liability. For example, if the law allows medical assistants to give injections under certain circumstances, but your policy states injections are given by registered nurses only, the medical assistant would be in compliance with the law but in violation of your policy. In addition, policies related to the standard of care provided to patients should be written with caution because detailed instructions that exceed the medically accepted standard of care may create possible malpractice liability. After reviewing relevant statutes, regulations, or guidelines, a plaintiff's attorney may request policy manuals to assess whether standards of care were breached. It could be damaging to your defense if your policies and procedures did not represent the accepted standard or if your staff failed to follow them.

For practices that are either hospital-owned or hospital-based, policies and procedures within the practice may need to be revised to reflect an integrated health system. Hospital risk managers and practice managers, and administrators must work together to identify areas where policy revision or implementation and subsequent education and training must occur.

Guidelines for Creating an Office Policy and Procedure Manual:

  • Begin with an introduction that describes the purpose of the manual.
  • State the office philosophy and the expectation that employees will adhere to the policies set forth.
  • Include an organizational chart with lines of authority by position.
  • Write realistic policies and procedures that avoid detailing matters related to the standard of care. Do not be restrictive by being too specific, yet avoid ambiguity and vagueness. A policy should be practical in carrying out the day-to-day operation of the practice.
  • Use straightforward language and avoid terms such as “shall,” “will,” or “must” in the policy or procedure, and do not use superlative words such as "highest quality" or "perfect."
  • Use a bullet point or numbered step format for ease in reading. A staff member should be able to navigate the policy quickly.
  • State the procedure step-by-step, following a logical sequence. Briefly outline who, what, when, where, and how of procedures.
  • Address patient/staff safety and health needs as priorities.
  • Ensure that the policy/procedure applies to all locations of a practice when appropriate.

Maintenance of the Office Policy and Procedure Manual:

  • Record the date when each policy or procedure is adopted.
  • Keep an up-to-date index or table of contents.
  • Perform reviews every three years for relevancy and compliance with current state and federal laws, or more frequently as new rules or laws become known or changed. If revisions are necessary, place revision dates on the new policy.
  • Retain a copy of each revised policy for the time period that is commensurate with your state's statute of limitations for filing a medical malpractice claim. See our practice tip The Life of a Malpractice Claim.
  • Practices with electronic policy platforms should discourage staff from printing and saving policies.  If printing is allowed, add to the policy header a statement, “This policy is only current on the day it was printed.  Current policies are located at ___________.”
  • Obtain signatures for policy approval from responsible parties.
  • Obtain input from an attorney or general counsel of the organization if there is a concern around a policy to make sure they are reasonable and achievable.

Staff Education Regarding Office Policies and Procedures:

  • Provide training to explain pertinent policies. Utilize policies and procedures as part of competency for staff as applicable. Consider an ongoing review of practice policies at staff meetings.
  • Obtain employees' signatures on a form indicating their review of the manual.
  • Enforce established policies. Monitor compliance with policies as part of quality improvement efforts.
  • Remind employees of their obligation to know practice policies and procedures and to follow them.

Policy Format

It is important to use consistent formatting.  Keep in mind that if you are part of a health system or are hospital-owned, you may have a set format that should be used.

  • Standard sections (as they apply)
  • Policy title
  • Policy purpose
  • Policy statement
  • Additional authority/reference
  • Scope
  • Definitions
  • Procedure
  • Equipment
  • References
  • Forms and attachments
  • Dates of origination of policy, the reviews, and revisions
  • Designated policy experts/contacts


Ask ECRI: Managing Policies & Procedures, May 2017

ASHRM: Physician Office Risk Management Playbook