Using Your Policy and Procedure Manual

Each unit should have a copy of the facility's policy and procedure manual (P&P) as well as a standards of care manual. Some facilities write their own manuals, others buy standard versions. Some facilities have a combination of both and cross reference to them. Be sure you know where these manuals are located and use them frequently. Make copies of pages as you use them to take home and review.

These manuals describe how a procedure is expected to be performed in this facility. You are expected to know this and never assume that the way you learned to do something is the only way to do it and is acceptable everywhere. Locate your manuals and read through them. Fill any free time you have, familiarizing yourself with the contents.

Each time you perform a new procedure, you must refer to these manuals first. Even if the procedure is not new to you, but it is the first time you have performed it in this facility, you must refer to the manual. You will show your preceptor that you are eager to do things correctly if you have already reviewed the manual before consulting with him to check you off on a procedure. Whenever you change jobs or facilities, one of the first things you need to do is to review the P&P for that facility. These manuals will be very different and very similar at the same time.

If your facility uses a purchased P&P, and you have used this P&P before during your schooling, don't assume you don't need to refer to it. This facility may have updated or changed portions of the manual and the only way you're going to know for sure is to check. By the same token, if you're about to do something you haven't done in a while; always check the manual for possible updates you weren't notified of.

If a particular doctor has his own way of doing something, he will usually bring it to the policy committee at a hospital and they will review it and incorporate it into their P&P manual. Therefore, the information in the manual is never carved in stone.

For example, a physician might have a very specific procedure for central line care. This might involve swabbing the site six times instead of the standard three times each with alcohol and betadine (or perhaps another antiseptic). Some might want a 2×2 used routinely, while some only want a transparent dressing. And there might be a particular way you must curl the line and secure it with tape or risk having your head torn off.

Your facility might have specific tasks that can only be performed by R.N.s even though most anywhere else an LVN can perform them. Your facility may have implemented very specific procedures for patient identification that must be used at all times. If you aren't familiar with the manual, you could be omitting an important step.

In addition to knowing the scope of practice or job descriptions, you must follow procedure in your facility to ensure safe practice and safe care for the patient. You are responsible for knowing this information.

The P&P might also include organizational information such as procedures for voicing a grievance, how often the manual is routinely updated and reviewed, what committees function in the organization and how to contact them, etc. Familiarize yourself with this and your standards of care manual. You may be able to answer many of your own questions, or bring intelligent questions to your supervisor or staff meetings.

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