UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE
TITLE: POLICY FORMAT AND REVIEW
Clinical Policies and Procedures
Effective Date: April, 2004 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education
Reviewed November 2007 January 2010 September 2013
To provide a process for the development and review of clinical policies and procedures at the University of
Wisconsin Medical Foundation (UWMF) and Department of Family Medicine (DFM) clinics.
Clinical policies are evidence based procedural guidelines providing step by step instructions of a procedure
carried out within the UWMF and DFM clinics.
1. Clinical policies and procedures will be written using the approved format.
2. Clinical policies are developed by clinical content experts and approved by the organizational leadership.
3. Clinical policies will be reviewed, updated and approved every three years, unless there is a change in
1. Each policy and procedure should include the following sections as appropriate: See template (link)
a) Purpose Statement: This statement provides direction, defines or establishes a process to follow. To
establish a process for personnel to accomplish a specific task.
b) Definitions: As necessary. Defines any unique terms used within the policy.
c) Policy Statement: Gives parameters of the policy, such as rules, standards, orders, and requirements.
d) Supplies: As necessary. List of specific items needed to carry out the procedural steps.
e) Procedure Statements: A step by step standard of how an activity or process is to be carried out. To
include when to use specific supplies, equipment, patient education and appropriate documentation.
1) References should be no more than three years old, if possible.
2) Both trade and generic names of medications should be used.
3) Abbreviations (unless commonly known) should be avoided or should include the full
name/title with the first appearance of the abbreviation.
4) Include specific name of HealthLink form, smart set, or smart phrase used for
5) Patient education materials referred to should be organizational approved resources or
1. The Clinical Staff Education department will manage the review time line of clinical policies using evidence
based practice from nursing and medical research. Additional reviewers may be sought as clinical experts
in their area, depending on the content of the policy.
2. Policies with medication dosages and administration shall be reviewed by a pharmacy representative.
3. The policy shall indicate the month and year it was reviewed. Attachments will be reviewed when
reviewing the policy.
4. Clinical policies will be sent to the UWMF Medical Director and to the Vice Chair, Department of Family
Medicine for approval and signature.
5. Specialty department policies will also include the approval and signature of the department’s medical
1. After policy has been approved, the Clinical Staff Education department will facilitate the posting of the
policy on UConnect.
2. For those policies with revisions, Clinical Staff Education department will send an email to the
managers/team leaders/nursing supervisors as necessary. All new policies will be communicated to the
3. The signed policy will be held in the Clinical Staff Education department – master binder.
WRITTEN BY: Ronnie Peterson, R.N., M.S., Manager of Clinical Support
REVISED BY: LaVay Morrison, RN, BSN, Clinical Staff Educator
REVIEWED BY: Lori Hauschild, MSN, Clinic Operations Director – Primary Care
Shabvon Johnson, MSN, Clinic Operations Director - Specialty
REFERENCED BY: 1.01 Ambulatory Policy and Procedure Format and Review, UWHC Departmental
Policy, Oct 2011
AUTHORIZED BY: Richard Welnick, MD, Medical Director, Ambulatory Clinic Operations, UWMF
Sandra A. Kamnetz M.D., Vice Chair, Department of Family Medicine
Medical Director, UWMF Date
Vice Chair, Department of Family Medicine Date