How to Write Medical Polices & Procedures

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The policies and procedures for a medical office or clinic are crucial to laying out the health care and administrative standards that clinicians are expected to meet. A policy and procedure manual tells doctors, nurses and other office staff how to perform certain duties so that they can provide quality care to patients. Since the health care industry is complex and is managed by numerous regulations, a policy and procedure manual also dictates which laws must be adhered to. Writing medical policies and procedures is an ongoing practice, as the changing laws in healthcare often mandate that your medical office's policies change, too.

  • Make a list of the categories or sections that you want to have in your policy and procedure manual. Examples of categories typically found in medical policy and procedure books include, but are not limited to, Insurance, Medical Filing, Claims Submission and Billing, Patient Safety, Employee Safety, Credentialing and Privileging, Pharmacology, Client Rights, Confidentiality and Employee Training.

  • Identify the legal requirements -- or licensing requirements -- that pertain to your line of medical work. For instance, if you are writing policies and procedures for a cardiology office, your clinic may have a specific set of regulations to follow that are different than the ones a pathology office needs to adhere to. In order to write effective policies and procedures, your policies must be in line with the federal regulations.

  • Create a template for your policies and procedures. Templates will help you keep each policy you draft consistent and standardized. The template should include the title or number of the policy, the purpose of the policy, applicability and the steps of the procedures that must be carried out. You might also include an addendum notice if the policy goes hand in hand with a particular medical form. For instance, if you are writing a policy and procedure for "patient intake," you would attach the patient intake form to the end of the policy.

  • Use your main policy categories to come up with individual policies. If your main policy category is Confidentiality, you might have two separate policies within that section, such as Electronic Security and Patient Health Information Disclosures. Under your Medical Filing category you might have policies for Timely Filing and Medical Records Requests.

  • Begin writing the procedures for each policy you want to include in your book. Write them directly into the templates and label them draft for now. Be as specific as you can for each policy you write. All steps should be clearly outlined and easy to understand.

  • Create a table of contents for your medical policy and procedure book. A table of contents helps keep things organized so that readers can find the policy and procedure they are looking for with ease.

  • Make sure your policies are HIPAA compliant. HIPAA, the Health Insurance Portability and Accountability Act, is a federal regulation that makes it illegal for health care entities to release patient health information without the patient's consent. Failure to follow HIPAA standards can result in your organization being fined for noncompliance, and can lead to a law suit if a patient feels like their confidentiality was breached.

  • Send your draft policies and procedures to the appropriate authority in your organization, such as the Medical Director or Chief Medical Officer, for review and final approval.

  • Review your policies and procedures on an annual basis to make sure that you do not have to make any changes to them. Add new policies to your book as they come up, and delete old ones that no longer apply.

References

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