Why have a policies and procedures manual?

A departmental policy and procedures manual for clinical coding is an essential management tool. Agreed policies and procedures provide a framework in which decisions can be made. They also allow consistency and continuity, which is particularly important when there are personnel changes.

Fixed policies and procedures can provide a basis for:

• standardising clinical coding practice

• eliminating duplicate activity

• testing and improving operations; and

• achieving greater understanding and co-operation amongst staff.

They also help in identifying requirements in staffing and training.

 What should the manual contain?

We give some guidance below on issues, policies and procedures.

1 – Issues

The key issues which should be included are:

• operational details (structurally and functionally)
• the source document to be used; and
• the process for resolving queries.

Issues should be written in a format that allows them to be updated easily.

2 – Policies

Policies set the boundaries within which action will take place. They should also reflect the philosophy of the department or organisation, and should include:

• a statement of purpose
• a commitment to national policy
• reference to other policies or guidelines
• timescales; and
• skill requirements of individuals.

3 – Procedures

Procedures are a series of steps, listed in chronological order and used to accomplish a specific task. Procedures should require minimal interpretation and be accompanied with correctly completed samples, where appropriate.

An effective way of developing detailed procedures is to ask an employee to write down all the steps required for a particular task, then to give these steps to another employee to see whether they are followed easily. The following suggestions may be helpful when it comes to writing procedures.

1. Determine all the steps, writing down only those that are required.
2. Work out the best sequence for these steps. Those that are similar or closely-related should be grouped.
3. Review the procedures that might be affected by changes in the others.
4. Test a procedure before it’s used.
5. Evaluate the procedure when it has been used for several weeks. Employees should be consulted, as they will give the most useful feedback.
6. Review and update policies and procedures annually, or more regularly if this is needed. 

Download a sample document

The following sample may help you in preparing a policies and procedures manual. It was submitted by West Midlands Data Quality Unit, and it incorporates good practice examples from regional trainers at the time.

• Download sample as a PDF (106kb)

This sample document is published in Word format so it can be easily adapted by Trusts. For further guidance, contact one of the Clinical Classifications Advisors listed in the Contact Us section.