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Policies and Procedures During the Planning Stage

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Policies and Procedures During the Planning Stage 


  • Identify the policies and procedures (P&P) in place within your system
  • Identify owners for these P&Ps
  • Consider creating a unified method to manage and update them
  • Consider placing them all on an intranet site
    • Consider making the P&Ps retrievable by a search engine
  • Be sure to include revision date, last reviewed date and owner on the document
  • Will you allow the use of scribes
  • How will you manage verbal orders, nurse initiated protocol



During this stage it is most important to get a handle on the number of policies and procedures in your hospital and /or clinic.  It is best to create a consistent method to index and identify the owners of them and to create a review process for each of them.  This will become necessary as you learn more about the changes in workflow brought about by CPOE and you find you will need to revise things.  Many sites have found it valuable to have copies of these documents posted on internal web sites so they can easily be referenced, indexed and retrieved with a search engine.