Document Management Guiding Principles


All clinical and operational documents will be stored centrally (in PolicyTech), regardless of scope or discipline. To create or revise a document, contact Accreditation at


Medical Center and Health System Policies supersede any discipline/unit/department (local) policy on the same topic. A local document can provide additional specifications, requirements, or restrictions than those provided in an existing document, but cannot contradict or duplicate it.


Documents will not duplicate existing documents (Health System Policy, Medical Center Policy, Lippincott Procedures, manufacturer's instructions for use).  In limited circumstances, in consultation with Accreditation, exceptions can be made for IFUs (ex. supply or equipment at high-risk for misuse, IFU difficult to retrieve, etc...).


Collaboration across disciplines and care areas to increase consistency of care for patients and streamline documents. 


Reach out to Accreditation (PolicyTech Owners) to create or a revise a document. Owners help categorize, title, template, and set the review path for the document. 


One or two (document writers) will be responsible for ensuring the document is current and has been vetted thoroughly by appropriate subject matter experts; including those that can review it against clinical, policy, and regulatory requirements. 


All documents are required to include reviewers. Reviewers are subject matter experts who will check for accuracy and content relevant to their functional area and/or role. 


All documents must be approved by the clinical or administrative leader or authorizing committee(s), as applicable, with oversight responsibility and accountability for the document's content. 


Documents will have a process and responsible party identified for implementation, including a plan for communication, staff education, and monitoring for effectiveness. For Protocol Orders, document writers must include a plan for periodic review of the order entry/cosignature report to monitor for proper use of the Protocol Order.