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About this Toolkit

This toolkit was first developed in 2011 when two groups of full service family practice physicians located in Sooke BC decided to come together as the West Coast Family Medical Clinic. In an effort to merge the teams and get everyone working together and comfortable with new processes, the founding physicians decided to involve staff in creating and maintaining an office manual. The South Island Division of Family Practice provided project management support to the Sooke physicians to launch their new clinic on condition any tools developed be made available to other family practice clinics.  

The toolkit has been available on the South Island Division website since 2012. It has been used as a resource by numerous family practices in South Island and Victoria, as well as several others across the province.

In 2015, Divisions undertook to update and expand the toolkit, and it is now available here on the Divisions website in various formats. Some clinics may choose to adopt certain policies and procedures as they are, and may find the web version of the toolkit the most practical. Some clinics may decide to develop their own customized manual from the downloadable MS Word version. An editing guide is available for those wanting to create their own manual. 

Toolkit Downloads

Practice Toolkit (Word) >
Editing Guide >

Toolkit Sections Available

*Starred sections available only in downloadable toolkit.

Chapter 1: Introduction >
    1.1 About This Toolkit >
    1.2 Making This Toolkit Your Own >
    1.3 Changes to This Toolkit >
    1.4 About [YOUR CLINIC] >
    1.5 [YOUR CLINIC NAME] Values >
    1.6 Clinic Organization >

Chapter 2: Clinicians >
    2.1 Introducing the Doctors >
    2.2 Doctors' Hours of Work >
    2.3 Clinician Contracts >
    2.4 Locum Arrangements >
    2.5 Clinician Recruiting >

Chapter 3: Staff >
    3.1 Roles >
    3.2 [YOUR CLINIC] Contact List >
    3.3 Employee Hours of Work and Pay Standards >
    3.4 Scheduling >
    3.5 Opportunities for Cross Coverage >
    3.6 Performance Monitoring Policy >
    3.7 Training and Professional Development >
    3.8 Personal Records and Administration >
    3.9 Employees as Patients >
    3.10 Vacation and Other Leave Requests >
    3.11 Relief Shifts >
    3.12 Employee Standards of Conduct >
       3.12.1 Attendance and Punctuality >
       3.12.2 Bullying and Harassment Policy >
       3.12.3 Bullying and Harassment Procedures >
       3.12.4 Gifts >
       3.12.5 Dress Code >
       3.12.6 P​ersonal Use of C​omputer, P​hone, Internet and Mail, and S​ocial Media >
       3.12.7 Privacy and Confidentiality >
    ​   3.12.8 Workplace Safety >
    3.13 Customer Service Standards >
    3.14 Employee Contracts and Agreements >

Chapter 4: Privacy and Confidentiality >

    4.1 Privacy >
    4.2 Privacy Officer >
    4.3 Privacy Policy Notice >
    4.4 Confidentiality Agreements >
       4.4.1 Staff >
       4.4.2 Third Parties >
    4.5 Responding to Patient Requests to Access Personal Information >
    4.6 Managing Privacy Complaints >
    4.7 Privacy and Security for [EMR] >
    4.8 Use of Technology >
       4.8.1 ​Use of Fax >
       4.8.2 Use of Email >
       4.8.3 Use of Social Media >
       4.8.4 Use of Photography and Video >
    4.9 Responding to Privacy Breaches >
    4.10 Secure Destruction of Personal Information >

Chapter 5: Emergency and Occupational Health and Safety >
    5.1 Critical Incident Reporting >
    5.2 Emergency Kits >
    5.3 Emergency Exits >
    5.4 Medical Emergency >
    5.5 Fire and Earthquake >
       5.5.1 Fire >
       5.5.2 Quake >
    5.6 Risks of Violence in Health Care >
    5.7 Procedures for Sharps Injuries >
    5.8 Workplace Safety >
       5.8.1 Routine Practices to Prevent the Spread of Infectious Disease >
       5.8.2 Preventing Transmission Respiratory Infection by of Airborne or Droplet Routes >
       5.8.3 Waste Disposal >

Chapter 6: Clinic Facility and Administration >
    6.1 The Facility >
       6.1.1 Facility Lease*
       6.1.2 Parking *
       6.1.3 Cleaning Contract*
       6.1.4 Garbage and Recycling*
       6.1.5 Clinic Areas*
       6.1.6 Opening and Closing Checklist >
       6.1.7 Exam Room Supply Standards*
       6.1.8 Sterilizing Medical Equipment and Tools*
    6.2 Administration*
       6.2.1 Clinic Address and Mail*
       6.2.2 Billing*
       6.2.3 Payments Accepted*
       6.2.4 Private Pay Schedule*
       6.2.5 Finance*
       6.2.6 Communications*
       6.2.7 Purchasing and Inventory*

Chapter 7: Telephones & Information Technology >
    7.1 Phones*
    7.2 Fax*
    7.3 Phone and Printer Directory*
    7.4 Internet*
    7.5 EMR*
    7.6 Clinic Website and Social Media*
    7.7 Video Conferencing*
    7.8 Systems Security*
    7.9 Backup and Recovery*
    7.10 Restarting Email and Fax Services*
       7.10.1 Instructions for Restarting Email Service*
       7.10.2 Instructions for Restarting Fax Service*
    7.11 System Downtime Procedures >

8. Patient Enquiries*
    8.1 Phone*
    8.2 Email*
    8.3 New Patients*
    8.4 Looking up PHN and Medication History*
    8.5 Requests to Transfer Records*
    8.6 Prescription Renewals*
    8.7 After Hours*
    8.8 Sick Note Requests*
    8.9 INR Calls*

9. Appointments*
    9.1 Standard Appointment Schedule*
    9.2 Appointment Types and Booking Preferences by Doctors*
    9.3 Drivers Physicals*
    9.4 Pre-Op Physicals*
    9.5 Injections*
    9.6 Wait List*
    9.7 Advanced Access – Same Day Bookings*
    9.8 Youth Clinic*
    9.9 Urgent Care Clinic*

10. Patient Encounters*

    10.1 Patient Arrival*
    10.2 Patient Prep*
    10.3 Set up for Pap or Minor Op*
    10.4 Exam Room*
    10.5 Appointment Completion*

11. Referrals & Prescriptions*

    11.1 Referrals In*
       11.1.1 Palliative Patients*
       11.1.2 [Other types of referrals in]*
    11.2 Referrals Out*
       11.2.1 Referrals to Specialists*
       11.2.2 Hospice Referrals*
       11.2.3 Travel Assistance for Referrals to Specialists*
    11.3 Prescriptions*

12. Maintain Patient Chart*
    12. 1 New Patients*
       12.1.1 Registering a New Patient*
       12.1.2 Registering a Family Member*
       12.1.3 Entering a Baby (still under Mother’s MSP)*
    12.2 Labs*
       12.2.1 Downloading Labs*
    12.3 Pap Recalls*
       12.3.1 To Generate a Recall List*
    12.4 Prescriptions*
    12.5 Allergies*
    12.6 Scanning and Filing Documents*
       12.6.1 Scanning*
       12.6.2 Filing*
       12.6.3 Types of Documents and Information Needed*

Appendices >
    Job Descriptions >
       Practice Manager Job Description [sample] >
       Medical Office Assistant Job Description [sample] >
    Employee Performance Development Plan Forms [samples] >
    Supply Location List [sample] >
    Uninsured Fee Schedule >
    General Express Consent Form [sample] >
    [YOUR CLINIC NAME] EMR Downtime Contingency Plan >
    Downtime Contingency Checklist >
    EMR Quick Guide and Shortcuts >
    Patient Code of Conduct >
    Opening and Closing Checklist >
    Partners of the [YOUR CLINIC NAME] >
    Visiting Specialists >
    Health Authority >
    Hospice >
    Physiotherapists >
    Occupational Therapists >
    Midwives >
    Pharmacies >

*Starred sections available only in downloadable toolkit.

Practice Toolkit Introduction Video



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