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Nursing Resources : Standard, Guideline, Protocol, Policy


A statement, reached through consensus, which clearly identifies the desired outcome. Usually used within audit as a measure of success. 

For example: 

The A1C test can be used to diagnose type 2 diabetes and prediabetes alone or in combination with other diabetes tests. When the A1C test is used for diagnosis, the blood sample must be sent to a laboratory that uses an NGSP-certified method for analysis to ensure the results are standardized.


A1C Level

Normal below 5.7 percent
Diabetes 6.5 percent or above
Prediabetes 5.7 to 6.4 percent


Systematically derived statements that help practitioners to make decisions about care in specific clinical circumstances. These should be research or evidence based.

National Guideline Clearninghouse


An agreed framework outlining the care that will be provided to patients in a designated area of practice. They do not describe how a procedure is performed, but why, where, when and by whom the care is given.

For example:

Nutrition Services protocol to designate food tray for patient with food allergy:

• The diet office notifies the tray line supervisor of the patient’s name, room number, and identified food allergies. 

• Special provisions include a designated workspace for the preparation of menu items to avoid cross-contamination.

• Food trays are lined with red placemats as a visual cue to staff that the meal tray is for a patient with a life-threatening food allergy.

•The supervisor then takes ownership of the meal tray to prevent cross-contamination, hand delivering the tray to the patient’s unit.


A formal written statement detailing the particular action to be taken in a particular situation that is contractually binding.

For example:

"It is hospital policy that patients may not be released until they receive medication instructions from a staff pharmacist prior to their discharge," or

"After a patient has been discharged, transportation services will deliver the patient to the exit in a wheelchair to ensure patient does not fall or injure themselves."