Procedure (template): Description of a series of steps required to complete a specific task, intervention or activity.
Protocol (template): A set of required actions to manage a clinical condition, operational issue or population occurrence. Any deviation requires documented rationale.
Algorithm (template): A process flow depicted in a graph. Can include a decision process or work process. An algorithm must be accompanied by a policy or procedure.
Guideline (template): Systematically developed, evidence-based strategies and principles that direct actions and decisions for management of specific circumstances. They provide direction for decision-making as well as allow for professional judgment. Generally broad based they describe roles and responsibilities for each professional.
Order Set (see Develop/Revise and Order Set): A set of precise instructions detailing actions for prevention, care and/or treatment of a clinical condition. On order set must be made client specific and signed by an authorized health care provider (prescriber). Frequently referred to as Pre-printed orders (in paper charts).
Policy (template): Is a clear, concise, non-negotiable, formal statement directing staff decision-making. It enables and guides informed action, prescribes limits, assigns responsibilities and accountabilities and is secondary to legislation and by-laws. It must align with the mission and vision of the organization. ALL staff are required to comply with the policy.
Standard Work (template): A precise description of a work activity including the sequence of tasks and the application of best practice to complete the activity. They ensure everyone know their roles and responsibilities and performs the procedures or tasks the same way each time. May be used to operationalize administrative tasks and/or care delivery in a specific area.
Reference Care Plan (template): An evidence-based care plan for a specific patient population/situation with embedded references that cite best practices.
Standard (template): A desired and achievable level of performance against which actual practice can be compared. It provides a benchmark below which performance is unacceptable. Standards are developed by expert and/or authoritative bodies.
Clinical Pathway: Defined plans of care for specific patient populations during a well-defined period of time. Interdisciplinary with criteria to guide care delivery they define the optimal timing and sequencing of interventions and treatments. Used to reduce variation in patient care they contain defined milestones with established outcomes. Any variances from the pathway are documented.
Form: A fillable sheet with demographic information and other related collected data.