PURPOSE (Arial, bold, 12, all caps)
Brief description of the purpose for this clinical practice support document.
POLICY STATEMENTS
Policy statements are non-negotiable, clear, formal and authoritative statements directing professional practice. They enable informed decision making, prescribe limits, assign responsibilities and accountabilities and are secondary to legislation and by-laws. Policies reflect the vision, mission, values and strategic directions of the organization. All staff are required to comply with policies.
Not all clinical practice documents will have policy statements. If present, there should be few. If there are over 5 policy statements required, attempt to categorize them into logical groups, using headings that make sense for the topic (e.g. “Pre-procedure”, “During procedure”, “Post procedure”, “Safety issues”).
Policies are stated in the positive (i.e. avoid “should…” or “it is recommended…”).
SITE APPLICABILITY
This section provides information regarding where in the organization the practice is applicable. List areas, programs where this practice applies or patient population this practice applies to; e.g., PICU, ED, cardiac sciences, oncology, etc. or site-wide.
PRACTICE LEVEL/COMPETENCIES
In this section all of the professionals who may enact this practice are listed. Included is the skill level required/expected of these individuals. It outlines any specific educational requirement that must be completed before the professional can engage in this practice.
Information may include:
- Basic Skill – The skill to enact the practice is a part of the practitioner’s basic education.
- Advanced Skill – The practice outlined has a degree of risk if not done with an understanding of the basic theory and correct actions. Outline the specific skill the practitioner must have or additional education, training or competency review that is required for the practitioner to have completed. If possible, specify.
- Specialized skill – An activity that has a high degree of risk, requires advanced education and is limited to a specific Professional Group or part of a Professional Group in a focused area of practice (e.g. IV therapy, epidural analgesia, Critical Care, etc.)
This section provides information regarding the particular practitioners that are impacted by the document/practice. It may also include professional roles and responsibilities, if required.
DEFINITIONS
Define terms used in the body of the document which will enhance understanding of the procedure.
Procedures describe a series of steps required to complete a task or activity and may provide the “how to” in a clinical Practice document.
Protocols outline appropriate actions for effective care and management of common clinical problems including assessment and intervention. They are generally profession specific and provide guidelines for decision-making (“ if … then …”) and can frequently be diagrammed as algorithms.
Algorithms are an effective method for solving a problem expressed as a finite sequence of steps (if this, then do that…). Flowcharts are often used to represent algorithms graphically.
Order sets/pre-printed orders are precise instructions detailing action for prevention, care and/or treatment of a clinical condition. These must be individualized to the patient and signed by an authorized prescriber in order to be enacted.
EQUIPMENT
List materials and equipment and how to obtain them if appropriate.
PROCEDURE / Rationale- Wherever possible, practices in the body of the document should reflect common practice in all affected practice areas. Small differences can be included in the body of the document. Provide a link to the more detailed area-specific information, if needed.
DOCUMENTATION
Include guidance about what information is essential to record and specific forms to be used, if applicable.
REFERENCES
List any references relevant to the development of the content in this section. References are expected to be current, i.e., published within 5 years or less. The reference list should contain a minimum of 1 reference less than 5 years old. If research on the topic is limited, note older reference as foundational.
Use APA Style in citing references.
WW.01.01AFetal Maternal Newborn & Family Health Policy & Procedure ManualEffective Date: Sep-20-2017
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