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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 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 Policies that do not comply with changes in state or federal laws, or are simply outdated may expose the practice to unnecessary risk.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, 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.

Policies should be reviewed to ensure they represent current practice. A reasonable time schedule for review is every three years. Medical Record Retention Recommendations for Physician Office Practices and Hospitals for at least the period of the statute of limitations.

For practices which 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 that avoid detailing matters related to 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, 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 quickly navigate the policy.
  • 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 triennial reviews for relevancy and compliance with current state and federal laws, or more frequently as new rules or laws become known. If revisions are necessary, place revision dates on the new policy.
  • Retain a copy of each revised policy for the period of time commensurate with your State's statute of limitations for filing a medical malpractice claim.
  • Obtain signatures for policy approval from responsible parties.
  • Obtain input from an attorney to ensure reasonable and achievable polices have been established.

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 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.

A policy must help an employee to make a decision. Communication among staff and efficiency of operations can be greatly enhanced by the presence of a well-written manual. Once a manual is in place, ensure that you and your staff live up to its contents.


American Academy of Family Practice, Create and Refine a Policy for Organizational Structure, 2012

ECRI, Risk Management Reporter, Risk Managers Tackle Challenges of Hospital-Acquired Physician Practices, April 2010.

ECRI, Physician Office Fundamentals in Risk Management and Patient Safety, 2008.

Risk Management Handbook for Health Care Organizations, Fifth Ed., Volume 3, 2006.

Johnson, Lee, JD, Medical Economics, Malpractice Consult, July, 2004.

Wee, MaryAnn, RN, Senior Risk Management Consultant of the Medical Assurance Company of Mississippi published in The Risk Manager, First Quarter, 2000.