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Policy and procedure manuals

To ensure the smooth running of your practice, you need to have a set of policies and procedures in place which underpin the workings of the practice; these state your goals, the plan to achieve your goals and any rules, as well as the modus operandi for the efficient management of the practice. General practices participating in the accreditation process will be required to have an appropriate policy and procedure manual.

Set policies and procedures

Established policies and procedures promote continuity and a positive team spirit as well as an atmosphere of efficiency, good communication and support. A comprehensive set of policies and procedures will assist in resolving disputes regarding performance and what tasks are required to be completed. Ultimately, a good set of policies and procedures should assist in the resolution of an industrial dispute.

Policies and procedures are in writing so that all practice members are aware of the overall direction and style of the practice, how you do business, and the appropriate action to be taken in a given situation.

Policies and procedures must be freely available to staff and all staff must be aware of how they are able to access (and make suggestions to improve) the policy and procedure manual.

See below for general suggestions, as well as a policy manual checklist for the type of procedures to include in your practice manual.There is also a policy guideline template and a policy manual template to help you get started or compare with your existing policies.



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  • All policies, guidelines and procedures should be outcomes-focused and based on the best available evidence at the time.

  • Keep all policies and procedures in a manual accessible to all practice members. This manual should be available both in a printed version, and ideally as a digital version in PDF format easily accessible by all staff on site (note that even in paperless offices there should still be a printed version on site).

  • All practice members should be required to read the manual and familiarise themselves with the content and layout. This should be an integral part of the induction process. All staff should sign and date a form to testify they have read it. Any future amendments should be read and signed by all staff. As an alternative, team meeting minutes where all staff are present and agree to policy can be counted as documentary evidence.

  • “Policy and procedure” should be a standing item on the agenda of every practice meeting, allowing for a new policy to be discussed or an existing policy to be examined.

  • New staff members should be set a small section of the manual to read (the most important sections is ideal) as part of early induction, to be followed up by management as a discussion to determine their comprehension of these and highlight the importance of the manual to all staff at the practice.

  • When staff ask a question they should be directed to the manual to find the answer.

  • When formulating policies and procedures, seek input from all practice members.

  • Coordination of policies/guidelines development and review should be the responsibility of a dedicated person allocated to the role (e.g. policy/guidelines coordinator).

  • Coordination of the typing, distribution and archiving of the policies/guidelines should be the responsibility of the policy/guideline coordinator.

  • Ensure that the manual includes a history of the practice, identifies standards and goals, describes operation and states the rules and regulations. It must be user-friendly, up to date, relevant, accurate and accessible to all practice members.

  • A manual should contain all the information needed to perform all practice duties. In theory a new untrained staff member should be able to use the manual to work in the practice unassisted. It should be a living document that is constantly changing to accommodate new developments.

  • All requests for new policies/guidelines or revision of existing policies/guidelines should be forwarded to the policy/guideline coordinator via the policy request form:

    1. The request for existing policies/guidelines should be met within one week, wherever possible.
    2. Requests for new policies/guidelines or modification of existing policies/guidelines should be considered in consultation with the author of that policy/guideline.
    3. Where new policies/guidelines are required outside of the scheduled review process, they should be written in consultation with the relevant author, and reviewed by at least one other relevant staff member.
    4. The person requesting the policy/guideline should also be informed of the outcome of their request within one week.


  • A standardised format should be used when writing policies/guidelines:

    1. Font specification should be Arial or Century Gothic Size 11 to allow easy reading. Format should follow the standard practice template.
    2. Each section of the policy/guideline manual should be a stand-alone document allowing for easier review/additions and distribution of updated policies/guidelines by section, rather than the whole manual, if required.
    3. Use diagrams wherever suitable to help make the manual user friendly and easy to read.
    4. Each section should be sequentially numbered.
    5. To control reviews and updates, the date of development and version should be noted in the footer.


  • References should be based on the best available evidence at the time and include international, national and state governing and professional bodies’ legislation, regulations and guidelines. In addition, any leading published research, best practice, etc. should also be included.

  • Wherever possible, references should be no more than five years old, unless they are seminal work or the current version. In this instance, they should be no more than ten years old.

  • All references should be stored/documented in a reference library, including source, availability and location.

  • All references should be stored/documented in a reference library, including source, availability and location.

  • Practices participating in the accreditation process will be required to substantiate their policies and procedures as part of accreditation which is carried out every three years.

  • Final policies/guidelines should only be distributed in hard copy or PDF ‘read only’ files wherever possible, to protect the original version.

  • A formal process should be available to allow feedback and input from the users, such as sign-off when they receive and approve of the policies/guidelines, a feedback form in the policy/guidelines manual to communicate any suggestions for improvement, and an annual satisfaction survey.

  • For medico-legal reasons policies/guidelines should be kept for at least seven years. An archiving system should be coordinated by the policy/guideline coordinator.

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This publication is proudly brought to you by Avant Mutual Group. The content was authored by Brett McPherson, reviewed by Colleen Sullivan and Avant Mutual Group.

This publication is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practice proper clinical decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgment or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published. © Avant Mutual Group Limited 2014.

IMPORTANT: Professional indemnity insurance products and Avant’s Practice Medical Indemnity Policy are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765. The information provided here is general advice only. You should consider the appropriateness of the advice having regard to your own objectives, financial situation and needs before deciding to purchase or continuing to hold a policy with us. For full details including the terms, conditions, and exclusions that apply, please read and consider the policy wording and PDS, which is available at or by contacting us on 1800 128 268. Practices need to consider other forms of insurance including directors’ and officers’ liability, public and products liability, property and business interruption insurance, and workers compensation and you should contact your insurance broker for more information. Cover is subject to the terms, conditions and exclusions of the policy. Any advice here does not take into account your objectives, financial situation or needs. You should consider whether the product is appropriate for you before deciding to purchase or continuing to hold a policy with us.