Good Nursing Policies and Procedures are the Blueprint for Quality Care

A long term care facility’s Nursing department policy and procedure manual should outline administrative policies and standards of care for basic nursing care procedures and all basic clinical practices.

It is the Director of Nursing’sresponsibility to review and update the manual at least annually to assure it is comprehensive and accurate. Updates must also be made when applicable due to changes in regulations or nursing standards of practice.

The master copy should be kept in the Director of Nursing’s office, and one copy placed at each nurses’ station so when policy or procedure is in doubt, staff can refer to the manual for clarity. To make it easier for staff to find subjects, it’s best if the manual includes a table of contents and an alphabetized cross-index.

The standard format for a procedure includes:

Statement giving objective goal of policy or procedure

Equipment and material needed

Staff the policy applies to, staff authorized to perform procedure

Documentation guidelines

Some facilities include in the policy and procedure manualmaster copies of long term care nursing forms. This helps to ensure uniform documentation throughout the facility.

Examples of policy and procedure manual topics:

Admissions and discharges

Blood sugar monitoring

Dressing changes

Feeding Tube

Isolation protocols

Lifts and transfers

Medication Errors

Post-fall protocol

Range of motion

Restraints

Standard precautions

Tracheostomy care

Urinary catheter insertion and care

Read more about topics of interest to the DON in long term care in the book Nursing Policy for Long Term Care and in the book  Director of Nursing Book .