business of Medicine


Onboarding Practice Managers Toolkit


Office Policy & Procedure Manual

Employees need to be able to refer to written guidelines when situations occur that they do not know how to handle. These guidelines give employees some reasonable knowledge of how to handle different types of patients, routine medical situations, administrative tasks, office safety and emergency situations.

There is no set format for a policy and procedure manual; however, there are a few points to keep in mind.

  • The manual should be straightforward and easy to understand.
  • The policies should state what is actually practiced, not what sounds good.
  • Each policy should contain an effective date and revision date.
  • Policies should be updated regularly, and a copy of any revised policy should be retained for 10 years.
  • The manual should address issues confronted in the day-to-day operation of the practice.


Personnel policies, including

  • Job description
  • Personal use of practice property
  • Dress code
  • Working hours
  • Sick leave
  • Vacation, holidays
  • Continuing education
  • Leave of absence
  • Confidentiality
  • Benefits
  • Performance appraisal
  • Probation, resignation and dismissal
  • Disciplinary procedure

Office policies, including

  • Health information practices
  • Release of information
  • Documentation
  • Telephone advice
  • Telephone technique
  • Follow-up on abnormal lab results
  • Scheduling
  • Billing/collections
  • Referrals/consultations
  • Terminating the physician-patient relationship
  • Patient education/instructions
  • Hazardous waste management
  • Equipment management
  • Claims/potential claims reporting procedure
  • Patient complaint procedure

Clinical procedures, including

  • Treatment protocols
  • Lab tests
  • Safety/infection control

Emergencies, including

  • Emergency numbers (911, poison control, police, fire)
  • Staff members’ responsibilities

Download our sample handbook here. 


The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.