Developing a policy 

Policies and procedures  

Policies are generally a position statement but because of the nature of general practice, these policies also include how the policy is implemented, therefore a policy and procedure are combined. 

A procedure is a written description describing the series of steps taken to achieve a desired result. 

The guidance

The guidance provides essential detail for each criteria, including a section on each policy/procedure and what they should contain and include. 


With clinical policies/processes where there is potential risk for patients, auditing is required to make sure that the policy and process are being adhered to. These policies/procedures include:   

  • 5.1. A documented clinical correspondence and investigations policy and procedure
  • 9.1.  A documented repeat prescribing policy and procedure.
  • 9.2. Documented standing orders policy and procedures.
  • 9.3. A documented medicine reconciliation policy and procedure in accordance with the Health Quality and Safety Commission Medical Reconciliation Standard 2012. 
  • 12.1 and 12.2 - Infection control and healthcare waste policies

How to structure a policy and/or procedure

Below is an example of a policy structure. Practices are not required to follow this format; however, assessors will be reviewing the practice’s policies and procedures for the main areas outlined below. Policies and procedures should be tailored to the practice. PHOs may have resources to support practices to create their own policies and procedures. 
The College has provided key elements to include for required policies and procedures.


Practice and logo
Name of policy/procedure 


Who does this policy apply to? 
Purpose/intended outcomes 

A brief statement to clarify the reason for this document 
Definitions of terms 

Any terms/words potentially not known to those using the policy / procedure 
Processes and procedures 

Describes how the policy is implemented and may include:  

  • Key elements (refer to guidance)
  • Timelines  
  • Roles and responsibilities of team members  

Refer and adhere to the applicable legislation  
Key relevant documents 

Include the following:  

  • Legislation 
  • Regulations 
  • Policies 
  • Procedures and standards 
  • Guidelines 
  • Forms
  • Other useful resources 

Document control 

  • Prepared by [name] 
  • Approved by [name] 
  • Owned/managed by [name] 
  • Date approved 
  • Next review date (minimum of 3 yearly)*
  • Page numbers 

The College has provided an example of a Child Protection Policy to show how a practice can use this structure to create a policy tailored to their practice.