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DHSS / Behavioral Health “Guidelines for
Writing Policies & Procedures”
Prepared by R.M. Calcote, M.S., LMFT and Sandra Warren
for State of Alaska Department of Health & Social Services, Behavioral Health
Policy and Procedure Manual
September, 2009
Table of Contents
PREFACE ................................................................................................................................ 2
GUIDELINES FOR WRITING POLICIES & PROCEDURES ........................................................ 3-12
When to Write Policy & Procedures ............................................................................................ 3
When to Revise Policy & Procedures ........................................................................................... 3
Goals for Developing Policies ..................................................................................................... 3
Policy Title Considerations .......................................................................................................... 4
Differentiating between Policy, Procedures and Desktop Instructions ...................................... 4
Composition Styles for Procedures ......................................................................................... 5-7
Writing Styles and Use of Language ....................................................................................... 7-9
Formatting Guide .................................................................................................................. 9-10
Grammar and Punctuation .................................................................................................. 10-13
1
Preface
In 2003, the Alaska Department of Health and Social Services (DHSS) created the
Division of Behavioral Health (DBH) by combining the Division of Mental Health and
Developmental Disabilities (DMHDD) with the Division of Alcoholism and Drug Abuse
(DADA). That merger joined two divisions with distinctly different operations. One
consequence of that merger was the subsequent lack of a coherent set of Policies and
Procedures. In response, DBH, now referred to as DHSS Behavioral Health
(DHSS/BH) created a new Policy and Procedure Manual in October 2009. This Guide
appears as an Appendix to that Manual.
The “Guidelines for Writing Policies & Procedures” is a reference for DHSS/BH staff
who are responsible for developing and writing policies and procedures for DHSS/BH.
It contains advice for when a policy should be written or revised. It provides guidance
on writing style, use of language, punctuation and grammar. It also provides direction
for the use of acronyms, abbreviations, and writing definitions of technical terms. The
document is organized in sections for convenient reference. In an effort to keep the
overall content consistent some material is repeated across the different sections.
This Guide is to be used in conjunction with policy number: BH – PP 1, “Policies and
Procedures Development and Approval Process”. This policy is referred to as the
“Index Policy” as it describes in detail how all subsequent DHSS/BH policies and
procedures are to be developed, written, and approved. Information related to the
writing and formatting of new policies and procedures, which are not contained in the
“Guidelines for Writing Policies & Procedures”, may be found in the Index Policy.
One final comment: Communication is a key component to developing effective policies
and procedures. A new or revised policy and procedures document typically obligates
employees as well as stakeholders to develop attitudes, knowledge, if not skill to carry
out the document’s intent and requirements. Information about new or revised policies
and procedures should be shared repeatedly through different methods to assure that
people have seen and understood the content. One time announcements are not
acceptable. People need to receive information through multiple means, such as email
distributions, letters, news items, meetings, and supervision. Complex policies and
procedures may also require training. Here again multiple and repetitive methods are
best. Training can be provided through lecture, workshops, on-the-job-training,
mentoring or computer-based media. Policy can only be effectively implemented
through purposeful communication.
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Guidelines for Writing Policies & Procedures
When to Write Policy & Procedures
Policies address what is required and why. Procedures address how a policy is to be
implemented.
In general a written policy should be considered in response to any of the following
conditions:
a. A need to establish a rule to govern operations
b. A need to eliminate confusion about what is required, and what is the appropriate
way to act.
c. To establish fair and consistent treatment
d. To establish accountability
e. When complaints or legal actions occur
f. When risk assessment indicates that an issue may arise
g. When an incident actually occurs and there is a good probability that similar
incidents may occur in the future
When to Revise Policy & Procedures
Revision of a policy and/or procedures should be considered:
a. Whenever a policy no longer reflects current practice
b. In response to new regulation or legislation
c. When there is conflict with other existing policy
d. When any of the elements of the policy or procedural steps need to be revised to
account for changes in personnel, department or division structure, or business
operations
e. When there are too many exceptions, exemptions or waivers to the policy
Goals for Developing Policies
All policies share the same developmental goals. When developing and writing new
policies consider the following statements:
1. A policy adds value to the organization
2. A policy serves as a high level directive from executive management
3. A policy is written such to ensure that the message is consistent each time it is
communicated
4. A policy is best developed through sufficient research and healthy debate
amongst all the various stakeholders
5. A policy addresses the long-term vs. the short-term
6. A policy improves risk management
3
Policy Title Considerations
All policies must have a title. When composing the title consider the following:
Ensure that the title accurately reflects the policy and procedural content.
Try not to start a title with words such as “the”, “that”, or “a”.
A policy title should be succinct.
Different policies that address the same or similar subject should utilize the same
terms in their respective title.
Differentiating between Policy, Procedures, and Desktop Instructions
When writing a policy and procedure document it is important to understand the function
of each element. Policy sets the rule to be observed. Procedures outline how to carry
out the rule. Desktop Instructions are separate and distinct from a policy and procedure
document. They are used to describe work flow to help employees perform a specific
job task. The descriptions and example below should help you better understand their
different purpose and structure.
Policy: Describes “What” and “Why”. It is a statement of the governing principle or rule
on a given subject and indicates the position and values of the organization. Policies
change infrequently and set the course for the foreseeable future. Policy is written as a
sentence or paragraph.
Procedures: Describes “How”. Procedures specify the critical sequential steps or
activities by which the policy is to be implemented. They are a written set of instructions
that identify positions and responsibilities, places, processes, forms and actions
necessary to carry out the policy. Procedures are formatted as numbered lists, two part
columns, or tables.
Desktop Instructions: Procedures that only address a single process. They are a
brief, detailed step-by-step set of instructions for performing a specific work activity.
They are typically only applicable to a sub-section of the organization and are not
connected with any specific policy. They may be modified to fit a present need without
a formal approval process.
Example:
“Dinner and a movie is the great American date.” ~ Policy
“To enjoy this activity: Invite your partner; buy flowers; make dinner
reservations; select a movie; wash the car; take a shower & dress; pick up
your partner in plenty of time to drive to a romantic spot to watch the
sunset before dinner.” ~ Procedures
“How to operate a car.” ~ Desktop Instructions
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Composition Styles for Procedures
Procedures can be challenging to write. While they must be clear and include all the
information needed to understand who, what, when and how, they must also be brief.
To make the process a bit easier we have listed some general rules for writing
procedures (below). Following the general rules are descriptions of popularly accepted
styles for organizing procedures.
General Rules:
1. Procedures NEVER include policy statements.
2. Procedures describe how to implement the policy, how to achieve the policy
objectives.
3. Procedures are always listed in sequence from start to finish.
4. Procedures always list responsibility for each step.
5. Procedures include only one action for each step.
6. Procedures utilize active verbs.
7. Procedures statements begin with an active/action verb whenever possible.
8. Procedures statements are written in present tense.
9. Procedures statements are written in third person.
10. Procedures provide sufficient detail with as little verbiage as possible.
Alternative Styles:
Step-by-Step Listing
This is the simplest way to organize procedures. It is basically a numbered list of
instructions or conditions. This format often uses multi-level lists with a subject
matter heading followed by primary, secondary, or even tertiary elements.
Example:
To prepare for the great American date:
1. Call to invite partner
2. Buy flowers at neighborhood florist
3. Make dinner reservations for two at favorite restaurant
4. Clean car
a. Wash car at drive-through carwash
b. Dry car
c. Wax car
i. Park car out of the sun, in shade
ii. Wax only painted surfaces
d. Vacuum interior of car
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Playscript
This is probably the oldest and most common format used for procedures.
Playscript organizes procedures into two elements: Action and Responsibility.
The content is typically formatted in two columns which provides uniform
appearance and enhances readability. Playscript is an effective way of writing
procedures that involve more than one responsible party. Playscript also allows
procedures to be written in action-condition logic as our whimsical example
demonstrates.
Example:
Responsibility Action
Courter 1. Call Courted to invite on great American date
Courted 2. Accept or reject invitation
If invitation accepted:
3. Reply with enthusiasm
If invitation rejected:
4. Reply sensitively without laughter
If invitation accepted:
Courter 5. Buy flowers at neighborhood florist
6. Make dinner reservations
7. Clean car
8. Clean self
If invitation rejected:
9. Call next number on favorites call-list
10. Repeat action steps 5 – 9 as they apply
Decision Tables
Decision tables also use action-condition logic. However, decision tables are
used to organize complex instructions so that they are more understandable to
the reader.
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Example:
IF THEN
Courter wants to go on the great Courter calls Courted with an invitation
American date
Courted accepts the invitation Courter:
1. Negotiates mutually acceptable
movie to see
2. Negotiates mutually acceptable
restaurant
3. Confirms pick-up time
4. Reassures Courted about
appropriate clothes
5. Buys flowers
6. Cleans car
7. Prepares self for date
Courted rejects the invitation Courted:
1. Explains why they have rejected the
invitation
2. Clarifies if future invitations will be
considered
3. Terminates call in socially acceptable
manner
Courter:
Chooses one of three available actions:
a) Call alternate Courted
b) Call best friend for different activity
c) Stay at home for the evening
Writing Style and Use of Language
This section provides tips and recommendations for composing the text of a policy and
procedure.
A. Write clearly and concisely:
1. Try to use only essential words
2. Use everyday plain language; ‘write as you would speak’
3. Use simple words rather than difficult to understand or uncommon words
(i.e. short words, 1-2 syllables long)
4. Use short sentences (3 – 12 words) and short paragraphs (40 – 100
words)
5. Be consistent; accurately repeat terms and phrases
6. Say what you mean, and mean what you say
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B. Use definitive and authoritative tone:
1. Use Present Tense
2. Use Active Voice
3. Write in third person
4. Use “must” or “will” if the action is mandatory
5. Use “should”, “could”, or “may” if the action is recommended
6. Use “shall” sparingly or only when referencing statutes or legislation;
clarify if the action is mandatory or recommended.
C. Organize your text for easy reference and readability:
1. Use numbered or alpha lists
i. To achieve brevity
ii. To help the reader easily reference information
iii. In procedures to show sequence
2. CAPITALIZE, bold, italicize, and/or underscore to emphasize key words
i. Use these enhancements consistently throughout the document
ii. Use especially with words that change the meaning or logic of a
sentence (e.g. not, if, except)
iii. Overuse of enhancements can be counter-productive
3. List documents or forms in the Attachment/Forms box of the P&P Title
Block that the reader should immediately read or examine to understand
the content of the policy and procedure
4. Reference other documents that support or authorize the P&P, such as
reports, Statutes, other P&P, as sequential Footnotes.
i. List Footnotes consecutively from beginning to end of P&P
ii. Reference material found on websites with the general or home
website address vs. the specific url for the document
5. Place foreign language phrases in italics
D. Follow the “Seven C’s”1:
1. Context – Actions must properly describe the activity to be performed
2. Consistency – all references and terms are used the same way every
time, and the procedure(s) must ensure consistent results
3. Completeness – There must be no information, logic, or design gaps
4. Control – The document and its described actions demonstrate feedback
and control
5. Clarity – Documents must be easy to read and understandable
6. Correctness – The document must be grammatically correct without
spelling errors
7. Compliance – All actions should fulfill goal of P&P and should work
efficiently and effectively
1
“Seven C’s to Avoid Procedure Writing Errors”, Chris Anderson; www.streetdirectory.com
8
E. Maintain integrity of the document:
1. Everyone who reads a P&P should be able to understand it and interpret it
correctly
2. Avoid use of gender specific references (use they or their vs. he/she)
3. Use plain text, with numbered or alpha lists as needed, in P&P
subdivisions and avoid the use of sub-headings or bullets
4. Use complete sentences, NOT fragmented or run-on sentences
5. Use Position Titles instead of personal names; especially in P&P
Responsibility section and Procedures Section
6. Avoid the use of jargon
7. Always define technical terms or cryptic words
8. Always spell out abbreviations or acronyms the first time they are
referenced in the document, followed by the acronym or initials in
parenthesis. Acronyms should always be written in CAPS, without
punctuation.
i. Example: Famous British Secret Service Agent, James Bond
(007), has rid the world of the scurrilous criminal organization
Special Executive for Counter-intelligence Terrorism Revenge and
Extortion (SPECTRE).
ii. Example: The defendant claimed that he crashed his car through
the revolving door of the hotel because he suffered from a rare
medical condition known as “delayed upload of the mediating
brainstem” (DUMB).
9. Whenever possible avoid using technical terms or acronyms in P&P Titles,
Purpose section, and Scope section.
10. The Policy statement should support both the P&P Title and Purpose
11. Be factual! Use only information that can be verified.
12. Interpret or reference [research] data accurately in the context for which it
applies. Explain the scope or limitations of the data as indicated, or
reference other reports which provide this information.
13. Use charts or graphs to display complex information rather than writing
long explanations in text.
Formatting Guidelines
Refer to the “DHSS/Behavioral Health P&P Template” attached to the Index Policy for
the accepted format for DHSS/BH policies and procedures. The following list provides
guidance for other formatting requirements:
1. Text should be written in Times New Roman, 11 pitch font
2. P&P Titles should be written in bold CAPS.
3. Section Headings should be written in bold 12 pitch font
4. Double space after periods
5. Double space between paragraphs, Sections, and sub-sections
6. Single space within paragraphs
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7. Use block design for paragraphs (i.e. do not indent)
8. Indent numerical and alpha lists .25 from the left for the first level, .50 for the
second level, and .75 for the third level.
Grammar and Punctuation
This section of the Guidelines is a reminder of what we learned in school about the
system of rules for the English language. However, space here is limited so only those
recurring rules that apply to technical writing will be covered. There may be other rules
governing structure (morphology) and sentence arrangement (syntax), etc., that the
writer may need to know. For that the writer is referred to either an English class or
texts on the subject.2 3
Grammar
A. Common abbreviations:
1. i.e. and e.g. are abbreviations that represent two words, so each letter is
followed by a period.
i. i.e. abbreviation for Latin id est:: that is
ii. e.g. abbreviation for Latin exempli gratia: for example
2. etc. abbreviation for Latin et cetera: and so forth; and other unspecified
things of the same class NOTE: etc. is preceded by and followed by a
comma
3. et al. abbreviation for Latin et alii: and others
4. R.S.V.P. abbreviation for French repondez s’il vous plait: please reply
5. id. abbreviation for Latin idem: the same Used in footnotes to indicate a
reference previously mentioned.
6. ibid. abbreviation for Latin ibidem: in the same place Used in footnotes
(and bibliographies) to refer to additional information in a book, chapter,
article or page cited just before.
B. Proper nouns:
1. Distinctive names given to places, buildings, objects, organizations and
personnel positions
2. The rule of thumb for proper nouns is to capitalize them AND to use the
capitalization consistently throughout the document
3. Position titles are to be used instead of personal names (e.g. Division
Director vs. Director Conn Troller)
C. Dates, Time and Numbers:
1. Standard format for dates is Month (spelled out), Date, Year (four digits)
2. Days of the week are spelled out (no abbreviations)
2 th
Geffner, Andrea B., Barron’s Business English, 4 Ed. Hauppauge, New York: Barron’s Educational
Series, Inc., 2004
3 nd
Rozakis, Laurie E., The Complete Idiot’s Guide to Grammar and Style, 2 Ed. New York, NY: Alpha
Books, 2003
10
3. Standard format for time: 24 hour clock
4. When referencing numbers in the text of a P&P use the number instead of
the word (i.e. 2, not two)
D. Language:
1. Use present tense
2. Write in third person
3. Begin procedure statements with an action verb
4. Use gender-neutral references
5. Instead of jargon, use words that everyone can understand
6. Use words, phrases and references consistently
7. Make sure technical terms are defined the same in the P&P and in any
Appendices
8. Consider using two sentences rather than a compound sentence
9. Consider using numerical or alpha lists rather than a compound sentence
or paragraph
10. Write clearly in a logical sequence
11. Use the preposition to and the adverb too properly
i. To: in a direction toward; for the purpose of (see any dictionary for
all usages)
ii. Too: in addition; also; excessively; very; immensely
12. Be clear which word you want to use to describe the order or arrangement
of something:
i. Number: a member of the set of positive integers (1,2,10…174,
etc.)
ii. Ordinal number: a number indicating position in a series or order
(1st, 2nd, 3rd, etc.)
iii. Cardinal number: a number used to indicate quantity but not
order (3, 22, 447, etc.)
iv. Serial: arranged in order of occurrence (e.g. serial numbers –
26,27,28,29,etc.)
v. Sequential: a following of one thing after another in chronological
or numerical order; order that indicates logical relationship or
recurrent pattern (5, 10, 15, 20, etc. or musical notes a,b,c,d,e)
vi. Consecutive: following successively without interruption; marked
by a logical sequence
vii. Continuous: extending without discontinuing; unceasing
13. Know when to use who and when to use whom
i. Who is used when the pronoun is the subject
ii. Whom is used when the pronoun is the object
Example: “Who is responsible for giving me a raise?”
- who is the subject of the verb “is”
“No-one knew whom the manager favored.”
- whom is the direct object of “favored”
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E. Defining Technical Terms:
First, do not leave the Definitions section of the P&P blank; there is always some
term to define in a P&P. Second, always define content from the P&P that also
appears in an attachment or reference. Third, expect that other people will use
different vocabulary and have different ideas for the meaning of technical terms.
That said, it can be difficult to explain the meaning of a word. While most people
in our industry can usually agree on the usage of a term, using other words to
describe that shared opinion can be problematic. Here are some tips for writing
definitions of technical terms:
1. Use a single sentence to define the term
2. Avoid using the term itself, or root of the word, in the definition
3. Use simple language
4. Use a dictionary or multiple dictionaries (especially dictionaries
dedicated to specialty subjects or industry)
5. Use a thesaurus for synonyms or ideas for describing the nuance(s) of
the term
6. Use the context for how the term is used in other documents to help
describe meaning
7. Poll stakeholders for descriptions and definitions; utilize their words and
intent to write a formal definition and seek feedback and consensus
8. Share the definition with someone unfamiliar with the term to check for
clarity and understanding
9. Confirm that the definition is consistent with how the term is used in the
P&P and supporting documents
Punctuation
A. Use a Comma:
1. To separate items in a series
2. To separate clauses in a compound sentence
3. Before the conjunctions and, but, or, nor, for and yet when they separate
main clauses in compound sentences.
4. Between words for clarity or to avoid confusion
5. After personal names or nouns of address
6. To bracket parenthetical expressions
7. To separate contrasting expressions
8. Between the parts of dates and addresses
9. Inside quotation marks
10. To bracket expressions like, however, after all, in general, etc.
11. Between a name and abbreviations or credentials, like Jr., Sr., or, M.D.
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B. Use a Semi-colon:
1. Between parts of a series or listings when the parts have commas within
them. Example: “Our hero, 007, battled the villains Hugo Drax, the Mad
Poisoner; Dr. Kananga, the Heroin Distributor; Trigger, the NKVD
Assassin.”
2. Between main clauses not joined by conjunctions (like and, but, because).
Example: “James Bond must always win the heroine; it reinforces his
mystique of infallibility.”
3. Between main clauses joined by a conjunctive adverb (like however,
therefore, for instance). Example: “Mankind has always used fictional
heroes to illustrate the power of good to overcome evil; therefore, James
Bond movies are necessary.”
C. Use a Colon:
1. After a statement that introduces a listing. Example: “Entertainment
Weekly has noted that the top ten Bond Heroines include: Tiffany Case,
Wai Lin, Xenia Onatopp, and Honey Ryder.”
2. After a statement that introduces a quote. Example: “One of the most
famous cinematic quotes is: “My name is Bond; James Bond.””
D. Use Capitals:
1. For all proper nouns
2. For important words in a title of a book, magazine, etc.
3. For position Titles
E. Parentheses or Brackets
1. Use parentheses to set off a statement or explanatory information within a
sentence.
2. Use brackets to indicate changes or clarifications in quotes. Example:
“Both hands on the wheel [Mr. Jones], I’m a very nervous passenger.”
F. Use Apostrophe:
1. To make possessives.
2. For possessive pronouns, such as Everyone’s and Everybody’s
3. To form the plural of letters and numbers (e.g. G’s, Q’s or six 5’s, etc.).
G. Use Hyphen
1. Between parts of a compound word, such as twenty-one, or mother-in-law.
2. Between a prefix and a proper noun (e.g. pro-British, un-Alaskan).
3. Between parts of a compound adjective (e.g. well-prepared, brave-to-a-
fault).
4. To divide words at the end of a line; MS Word performs this action
automatically.
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