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Put It in Writing: Your Office Policies and Procedures

by Corporate Relations and Business Strategy Staff

Having clear, well-documented office policies and procedures is essential to running a successful practice. From reducing the likelihood of client misunderstandings about matters like scheduling, payment and cancellations, to streamlining personnel management and setting clear expectations for your staff, your policies and procedures are one tool for managing the risk inherent in running a business. Although some types of policies are relevant to most practices, the extensiveness of your policy manual will depend on the way your particular practice operates, as well as whether you have support staff — and if so, how many people you employ.

What to Include
Your policies and procedures manual should address most major aspects of your practice operations. Typical categories include:

  • Organizational mission and structure 

  • Administrative procedures 

  • Facility management 

  • Office policies related to clients and their records 

  • Employment and human resource issues 

  • Workplace health and safety

If you are a solo practitioner without support staff and handle all of your administrative activities yourself, you will have less need to document all of your administrative operations and your policies and procedures may focus primarily on office policies related to your clients and their records. At the other end of the spectrum, if you have a large practice or a more complex organization or employ a greater number of support staff, you will need to have more extensive documentation that establishes your compliance with various federal and state employment laws and regulations.

What to Avoid
Although a policies and procedures manual can be an effective tool to help you run your practice, manage your staff and reduce your liability risks as an employer, there are several safeguards that can prevent future headaches and reduce the likelihood of employment-related complaints and lawsuits.

  • To reduce the likelihood of issues such as wrongful termination suits, breach of contract claims or other employment-related lawsuits, be sure that your policies and procedures manual does not inadvertently create an employment contract. Include a disclaimer in your documentation that states the manual serves as a guide to the practice’s policies and procedures and does not explicitly or implicitly create a contractual relationship. 

  • Take care not to use language that locks you into providing specific “guaranteed” benefits. Include a statement in your disclaimer that indicates your right to modify the policies, rules and benefits at any time. 

  • In policies related to termination of employment, avoid using undefined, catch-all terms such as "just cause" which may open the door for wrongful termination lawsuits. 

  • Avoid writing policies and procedures with language so specific that it is difficult to comply with, makes it challenging to operate your practice effectively or interferes with your ability to flexibly handle specific situations that may arise.

Cover Your Bases 

  • Have a labor or employment attorney review your policies and procedures for language and compliance issues. If you have more than just a few employees, consider having a labor attorney write the employment sections of your manual — there are a variety of federal and state laws and regulations that may apply to your practice, depending upon how many people you employ. 

  • Check the U.S. Department of Labor’s (DOL) website and that of your state’s department of labor. The DOL’s Office of Small Business Programs offers a variety of compliance resources for small businesses. 

  • Be sure you are in compliance with any other regulatory bodies connected to your practice. 

  • Review your policies and procedures at least once a year. Make any changes necessary to keep your operations flowing smoothly and to comply with any legal or regulatory changes. Store your policies and procedures in a format that is easy to update. For example electronic files and binders give you the flexibility to make changes to one section without having to rework the entire manual. 

  • Make sure your staff members have access to the policies and procedures. Have your employees sign a statement that they received the policies and procedures and agree to comply with them. Keep a copy of this signature page in their personnel files and have them sign new acknowledgements any time you revise or update your policies.

Examples of Policies and Procedures

NOTE: The following topics are provided as examples only and neither apply to all practices, nor represent a comprehensive list of all policies that may be beneficial or required. Be sure to talk to your attorney and check with the U.S. Department of Labor, your state’s department of labor and any contracting and regulatory bodies to determine the policy and procedure requirements applicable to your specific situation.

Organizational Mission and Structure 

  • Facility contact information (address, phone, e-mail, website) 
  • Practice mission statement 
  • Core values
  • Organizational structure

Administrative Procedures 

  • Mailing 
  • Printer, copier, telephone and fax machine usage 
  • E-mail and internet policy 
  • Accounts receivable (handling cash, checks and credit cards) 
  • Billing and claims submission 
  • Accounts payable (payment of invoices, signature authority) 
  • Purchasing supplies 
  • Petty cash

Facility Management 

Office Policies Related to Clients and Their Records 

  • Office hours 
  • Scheduling appointments 
  • Cancellation policy 
  • Informed consent 
  • Privacy and confidentiality (including compliance with HIPAA privacy rule requirements
  • Limits of confidentiality 
  • Client records (order, maintenance, disposal, release and transfer, client access) 
  • Policies and procedures designed to prevent, detect, contain and correct HIPAA security violations

Employment and Human Resource Issues 

  • Description of hiring process (e.g., application, reference check, interviewing) 
  • Statement of “At Will” employment status 
  • Personnel files and employee records 
  • Equal Opportunity 
  • Harassment policy 
  • Job description 
  • Wage and salary information 
  • Pay periods 
  • Performance evaluations 
  • Attendance policy 
  • Vacation, holiday and sick time 
  • Flexible work arrangements 
  • Overtime 
  • Benefits and eligibility requirements 
  • Insurance 
  • Retirement plans 
  • Workplace conduct (e.g., relationship with clients, confidentiality, dress code) 
  • Disciplinary action 
  • Termination (voluntary and involuntary) 
  • Exit interview

Workplace Health and Safety 

  • Emergency procedures 
  • Emergency and disaster contingency plans 
  • Reporting accidents and other incidents 
  • Workers compensation 
  • Smoking policy 
  • Drug and alcohol policy 
  • Client emergencies and after-hours care 
  • Employee health and well-being efforts

PLEASE NOTE: Legal issues are complex and highly fact-specific and require legal expertise that cannot be provided by any single article. In addition, laws change over time and vary by jurisdiction. The information in this article should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions regarding individual circumstances. The statements and opinions published herein do not represent official policies, standards, guidelines or ethical mandates of the American Psychological Association or the American Psychological Association Practice Organization.


Date created: 2005