In any workplace, having a list of employee policies and procedures is important for a variety of reasons. These include ensuring that the workplace complies with state law, federal law and industry regulations, eliminating guesswork on employees’ parts when facing new or challenging situations, standardizing the care provided by employees and quickly teaching new employees how to work effectively with the team.

In a hospital or clinical setting, a comprehensive set of nursing policies and procedures protects the nurses and the patients from confusion and harm. Policies are guiding principles, while procedures are actionable instructions.

Draw From Existing Nursing Policies

Nurses and other health care professionals are legally required to comply with certain federal laws, such as the Health Insurance Portability and Accountability Act and the Emergency Medical Treatment and Labor Act (EMTALA). A health care policies and procedures manual should be written with these requirements in mind and reference them in a clear, complete manner because when such policies are covered in vague or confusing language, the hospital can potentially face legal action from patients who felt they suffered due to policy violations.

For example, a hospital’s EMTALA policy should exactly state that the hospital will act in accordance with the law when facing a patient with emergency medical needs rather than simply stating that the hospital complies with EMTALA regulations. In many cases, hospitals turn to medical lawyers to write these parts of their policy manuals.

In addition to federal law, an individual or committee creating a set of nursing policies can look at other health care providers’ policies to see how an effective policies and procedures manual looks.

Examples of Health Care Policies

Policies are principles that guide actions and decisions. Typically, an organization’s procedures are derived from its policies. Examples of health care policies to implement in hospital and clinical settings include:

  • Always consider the patient’s religious and cultural needs when administering care.

  • Provide an ASL interpreter for all deaf and hard-of-hearing patients.

  • Always refer to the procedure manual when you are unsure of how to perform a specific task.

  • Use person-first language when speaking with patients.

  • Report all falls, spills and other accidents as soon as possible.

Examples of Health Care Procedures

Health care procedures are the standard steps that nurses are to take when facing specific scenarios. They are written in much more precise language than health care policies because instead of acting as guiding principles, they are explicit instructions.

Often, the link between a clinic or hospital’s nursing policies and procedures is fairly easy to recognize. For example, a clinic that includes respecting patients’ religious and cultural sensitivities in its list of policies might make asking all new patients about their specific cultural and religious needs a standard procedure.

Health care procedures can be complex and can involve multiple steps for nurses to follow. Some hospitals and clinics make their nursing procedures available online for patients and caregivers to view, which can help them understand the care they receive and enable them to advocate for themselves during interactions with nurses and other health care staff.

Writing a Health Care Policies and Procedures Manual

When writing a set of nursing policies and procedures, hospital or clinical management can look at examples of health care policies that align with patient-protection laws and the standard of care for the conditions handled by each department. A well-written policies and procedures manual can protect nurses, doctors and other hospital staff from potentially facing medical malpractice claims from patients who are injured by health care provider error or failure to comply with the standard of care for their conditions.

A health care policies and procedures manual should also include employment policies and procedures for nurses like:

  • Sick time and vacation day policies.
  • Pay period schedule.
  • Sexual harassment policy.
  • Anti-discrimination policy.
  • Short-term disability leave policy.
  • Procedure for disputing human resources decisions.
  • OSHA workplace safety requirements.