How to Document a Protocol


Taking a basic business process or understood protocol in practice and documenting it for standardization involves a number of critical steps. Much of the work depends on the accurately recording each step and then validating whether it is correct or not. Using a review process and eventually a feedback opportunity helps refine a protocol so that it becomes a best practice of behavior in an organization.

Identify a business practice that is used regularly by staff and needs to be written down. Write down notes about the process and what is known already. Organize the notes in bullet format with a title for each step and the details as sub-bullets under each title.

Pick a set number of staff who perform the function enough that they have sufficient experience to describe it verbally. Interview at least three persons involved, with at least one being a supervisor; you can interview more if you have the time. Follow these personnel through the activity as they perform it when possible. Shadow their actions and steps and take notes on each activity.

Begin the draft documentation of the business process and protocol by collecting your notes onto a computer with word processing software. Organize your notes so that they can be easily read and the reader can follow the process from beginning to end and result.

Edit the document for clarity. Perform and obtain independent research outside of the organization to determine what best practices should apply to the specific business process if any. Incorporate this research into your edited note file. Print out a complete first draft.

Identify key staff and managers who work with the studied business process regularly. Incorporate them into a review team to discuss and review the draft document, allowing them to suggest edits or changes based on their experience and knowledge. Record all identified results or expected reaction to the idea of documenting the protocol.

Finalize the reviewed product with edits that help refine the document. Make changes as necessary if identified potential results suggest a new direction in the steps to avoid problems. Prepare a final copy of the written protocol and authorize it for distribution to all the staff. Send out an immediate notice to everyone affected and include the protocol in accessible guidebooks that can be referenced later on in the future.

Tips & Warnings

  • Followup on feedback regarding the now-documented protocol. Make additional changes as necessary based on the feedback and issues found when the written protocol was followed.
  • Once a written protocol is edited and approved as final, it needs to be distributed widely within the organization or business so all the staff and read it. Good distribution includes an email or paper notice to all affected staff.

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