Policies and Procedures Manual

Introduction

The facility’s Nursing department policy and procedure manual outlines administrative policies and standards of care for basic nursing care procedures and clinical practices.

The Director of Nursing should review and update the manual at least annually to ensure it is comprehensive and accurate. Updates should also be made when applicable due to changes in regulations or nursing standards of practice. Other appropriate additions to the manual would be manufacturer guidelines and instructions for new equipment and devices. Some facilities have a policy and procedure committee that meets several times per year to review and consider changes to the manual.

The form at the top of each policy and procedure has spaces for the date the policy and procedure was approved by the Director of Nursing and the date of any addendums or changes.

The master copy of policies and procedures should be kept in the office of the Director of Nursing, and copies can be placed at each nurses’ station so when policy or procedure is in doubt, staff members can refer to the manual for clarity.

Some facilities include with the policy and procedure manual master copies of forms, and this can help to ensure uniform documentation throughout the facility.

Individual policies and procedures may also be used as teaching tools in an inservice or employee counseling session.

Each of the policies and procedures in this manual are also included on the CD which is located in the back of the manual, so they may be easily edited on a word processor for desired updates and changes.