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BOC Guiding Principles for AT Policy and Procedure Development UPDATED JUNE 2026 BOCATC.ORG/POLICY BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENTBOCATC.ORG 2 Table of Contents INTRODUCTION3 POLICY MAPPING AND NEEDS IDENTIFICATION 6 7 Introduction and Operational Definitions6 Employee Safety8 Facility Management12 Patient Care 16 Information Governance and Data Security22 Risk Management 25 TEMPLATE POLICIES 287 Administrative Functions and Facility Procedures28 Communication of Protected Health Information28 Concussion Management28 Crisis Management Communication Plan 28 Medical Documentation 28 Medication Storage, Administration and Disposal 28 Mental Health Management 28 Sudden Cardiac Arrest28 Workplace Injury and Illness28 Emergency Action Plan28 Exertional Heat Illness28 APPENDICES 29 Appendix A: Policy and Procedure Template30 Appendix B: Policy and Procedure Handbook Introduction Examples31 Appendix C: Checklist for Development Review of Individual Policy/ Procedures 34 DISCLAIMER 41 BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENTBOCATC.ORG 3 BACKGROUND The “BOC Guiding Principles for Policy and Procedures Development” was originally created by the Facility Standards Work Group in 2016 and updated in 2022 and again in 2025. The goal of the most recent revision was to align with current literature and enhance understanding of policies and procedures for health care delivery across various athletic training practice settings. The 2025 work group included: Ericka P. Zimmerman, EdD, LAT, ATC, FNAP (Co-chair)) Samantha E. Scarneo-Miller, PhD, LAT, ATC (Co-chair) Brian Bratta, PhD, ATC, CSCS Mark D’Anza, MEd, LAT, ATC Mike Hopper, MS, LAT, ATC Rebecca M. Lopez, PhD, ATC, CSCS, FNATA Edward J. Sedory MEd, LAT, ATC, EMT-T Richelle M. Williams, PhD, ATC The BOC Guiding Principles for Policy and Procedures Development document provides resources and considerations to assist in reviewing and developing policies and procedures in a manner that provides guidance and acts as a starting point for Athletic Trainers (ATs). In addition, the provided samples and templates allow for streamlined translation to practice, reducing the time burden on ATs. It is important to note that these templates are meant as a guide and are not legally binding documents. It is best to establish procedures that align with your facility’s needs, while incorporating evidence-based guidance and complying with applicable state laws, federal regulations and organizational policies. Furthermore, each organization and facility may include their own policies or procedures; therefore, ATs should seek guidance during development and use organizational standards as a precedent. The available templates can be used as additional resources for developing policies and procedures. Developing and implementing policies and procedures are critical parts of organizational risk management. Worksheets, templates and sample documents are included to help guide the reader in developing policies and procedures specific to their organization. Importantly, the templates and samples provided are not tailored to an individual organization (i.e., will require additional information for your organization) and are not all-encompassing (i.e., there are only a select number of templates; other topics warrant policies and procedures that are not provided in this document). The following resources will help gauge your health care facility’s compliance with applicable state, federal and oversight agency regulations and best practices. POLICIES AND PROCEDURES Policies and procedures are critical to any risk management plan; providing individuals with clear expectations and instructions to fulfill the organization’s expectations allows for implementation and standardization in daily operational activities. 1,2 Policies and procedures clarify intent and activities critical to health and safety, legal liabilities and regulatory requirements. 1 Organizational leaders use these documents to help communicate desired outcomes and expectations to employees and other individuals; further, they help clarify roles and responsibilities within the organization. 1,3 When policies and procedures are established, safe, effective and organized care can be delivered. The review and development of policies and procedures may be best led by a singular person (i.e., a policy and procedure coordinator). 4 Development should incorporate feedback and ideas from relevant individuals which could include community partners, organizational leaders, coworkers, key health providers, coaches, athletic administrators, organizational leadership, emergency medical services, facilities personnel, etc. Policies and procedures should be written based on the best available information for the topic area, which may include (but are not limited to) position statements, consensus documents, inter- association task force documents, roundtable documents, original research articles, case law and applicable state, federal and agency regulations. Introduction BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENTBOCATC.ORG 4 Introduction For ATs working per diem or employed on an ‘as needed’ or floating basis, it is important to review the policies and procedures established for each employer and employment setting. If no policies or procedures exist, the AT or policies and procedures coordinator should work with organizational leadership to develop appropriate policies and procedures. These policies and procedures should outline safety protections for patients and the facility, along with any administrative responsibilities. DIFFERENCES BETWEEN POLICIES AND PROCEDURES, EMERGENCY ACTION PLANS AND STANDING ORDERS Understanding differences between policies and procedures, standing orders and emergency action plans is important when developing and implementing each document into the work environment, and how they work together. 5 Policies establish the overarching rules or expectations for care and daily operations, while procedures outline the step-by-step actions to carry out those policies in practice. 5 An Emergency Action Plan (EAP) is a specific, detailed protocol that guides the immediate response to various emergencies in different venues, ensuring everyone knows their roles during a crisis. 4 An EAP is written to aid in the response to any type of injury which warrants emergency or urgent attention. 4,5 An EAP includes general information about how personnel will respond to an emergency and should not have condition-specific information. In contrast, policies and procedures are condition specific. These two documents support each other and are often activated or implemented synonymously. For example, for a patient with exertional heat stroke, activation of the EAP will indicate summoning EMS, delineate roles and responsibilities, and provide venue addresses. In parallel, the exertional heat illness policy and procedures will describe the recognition and treatment parameters specific to exertional heat stroke and where the cold-water immersion tub is set up and the procedures to implement cooling. Standing orders are written medical directives that authorize ATs under the direction of a physician to perform specific clinical tasks or interventions without prior approval for each instance. Standard operating procedures (SOP) or school-based operating procedures encompass policy and procedure or school-day activities, including classroom procedures, in the event of an environmental disaster. 6 In some settings, a SOP is the equivalent of the procedures in a policy and procedure handbook. ATs should work with organizational personnel to understand school- based procedures and incorporate any specific policies or procedures appropriate for athletic training medical coverage. Together, these documents form a comprehensive framework to guide safe, efficient and legal delivery of care. ADVANTAGES OF POLICIES AND PROCEDURES Provide Structure to the Program - Well- written policies and procedures provide structure for an organization, regardless of size. By creating policies and procedures, organizations “know what the rules are” and how to measure compliance. Further, they promote operational and organizational efficiency by streamlining workflows, reducing redundancy and ensuring that all staff follow consistent, clearly defined processes. Provide Guidelines - Policies and procedures communicate the organization’s expectations, guide action and help employees, supervisors, colleagues and patients understand their jobs and responsibilities. A policy and procedure handbook also lets employees and supervisors know how to respond to issues that might arise during business. Consistency in Quality Care and Improved Patient Outcomes - A clear policy framework reduces misunderstandings and ensures transparency and consistency in organizational operations and decision-making. Importantly, well-defined policies and procedures promote continuity, allowing for consistent practices despite staff turnover or multiple providers within a single clinic. These documents can optimize patient outcomes by standardizing care practices, ensuring timely and evidence- based interventions and reducing variability in treatment across providers. Promote Proactive Planning - Policies promote proactive planning by establishing clear expectations and guidelines in advance, ensuring consistent, evidence-based decisions before emergencies or challenges arise and in the day-to-day operations of the facility. Adherence to Laws and Organizational Regulations - With the rapid pace of new and updated laws and organizational policies, organizations may struggle to adhere to and communicate ever-changing regulations and best practices. 7–10 When kept current, a policy and procedure handbook helps providers ensure compliance with all laws and simplifies communicating change organization-wide. BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENTBOCATC.ORG 5 Introduction Risk Management - Policies and procedures must align with local, state and federal laws and regulations and organizational or agency requirements (e.g., JCAHO, NCAA, NAIA, JUCO regulations, high school athletics associations, OSHA, Defense Health Agency, depending on the setting). As laws and regulations frequently change, keeping policies current and effectively communicating updates to all relevant staff can be challenging. To maintain compliance and consistency, policies and procedures should be reviewed, updated and approved annually, with the previous version retained as part of the organization’s risk management plan. SUMMARY Policies and procedures are living documents, which should be reviewed and updated regularly. Policies and procedures connect an organization’s vision and goals to internal operations. They are internal controls that are vital to accountability within the organization’s structure. Policies create an expectation or guide for an action within the organization, while procedures include step-by-step directions to carry out each policy, providing a road map for an organization’s workforce. BIBLIOGRAPHY 1.Dunbar-Gaynor M, Zimmerman EP, Liberi V. An Examination of Policy and Procedure Practices of Secondary School Athletic Trainers. I Jour Allied Health Sci and Practice. 2020;18(2):1-7. 2.Diehl J, Dean C, Kilgore D, et al. Guiding Principles for Athletic Training Policy and Procedure Development.pdf. Published online 2016. chrome-extension:// efaidnbmnnnibpcajpcglclefindmkaj/ https://www.bocatc.org/system/comfy/cms/ files/files/000/000/529/original/Guiding_ Principles_for_AT_Policies_and_Procedures. pdf 3.DiMartino T. Section 5(a)(1) of the Occupational Safety and Health Act of 1970 (29 U.S.C.654) and 29 CFR 1960.8(a) for federal agencies. Available at https:// www.osha.gov/pls/oshaweb/owadisp.show_ document? p_id=3359&p_table=oshact. 4.Scarneo-Miller SE, Hosokawa Y, Drezner JA, et al. National Athletic Trainers’ Association Position Statement: Emergency Action Plan Development and Implementation in Sport. J Athl Train. 2024;59(6):570-583. doi:10.4085/1062-6050-0521.23 5.Scarneo-Miller S, Yeargin SW. Knowing the Difference: Developing and Differentiating Institution-Specific Health Care Administration Documents. NATA News. Published online February 2022:34-36. 6.Developing and Maintaining Emergency Operations Plans. Comprehensive Preparedness Guide 101, Version 2.0. Published online November 2010. 7.Adams WM, Scarneo SE, Casa DJ. State- Level Implementation of Health and Safety Policies to Prevent Sudden Death and Catastrophic Injuries Within Secondary School Athletics. Orthopaedic Journal of Sports Medicine. 2017;5(9):1-8. 8.Scarneo-Miller SE, Eason CM, Adams WM, Stearns RL, Casa DJ. State- Level Implementation of Health and Safety Policies to Prevent Sudden Death and Catastrophic Injuries Within High Schools: An Update. Am J Sports Med. 2021;49(12):3372-3378. doi:10.1177/03635465211031849 9.Johnson ST, Koester MC, Bovbjerg VE, Norcross MF. The Effect of a Statewide Policy on High School Emergency Action Plans. Sports. 2022;10(10):161. doi:10.3390/ sports10100161 10.Pagnotta KD, Mazerolle SM, Pitney WA, Burton LJ, Casa DJ. Implementing Health and Safety Policy Changes at the High School Level From a Leadership Perspective. Journal of Athletic Training. 2016;51(4):291-302. BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENTBOCATC.ORG 6 Policy Mapping and Needs Identification To support the evaluation and development of policies and procedures within the health care facility, this section provides a structured approach to policy mapping and needs identification. Five targeted worksheets have been designed to help you systematically review and align policies across key operational areas: •Employee Safety •Facility Management •Patient Care •Information Governance and Data Security •Risk Management Each worksheet serves as a practical tool for identifying the necessary policies for one’s facility or cross-referencing existing policies with recommended best practices. For each listed policy and procedure, indicate whether it currently exists or is needed, and use the provided space for notes to document observations, action items or next steps. The process helps identify gaps in policy framework, prioritize areas for development or revision and ensure alignment with regulatory standards and organizational goals. An online version of this tool is also available on the BOC website for those who prefer a digital workflow. Use these worksheets as a starting point for thoughtful policy review and strategic planning. Individual policies can be further evaluated using the Checklist for Development and Review of Individual Policies and Procedures in the appendix. When developing policies and procedures, it is essential to ensure they are consistent with and reference current employer guidelines. If no employer policy exists, ATs should develop procedures based on established best practices within the athletic training field, ensuring they meet legal, ethical and safety standards. If an existing employer policy conflicts with professional best practices, document the discrepancy and address it through appropriate channels, such as consultation with leadership, risk management or legal counsel, to advocate for alignment with evidence-based standards and patient or employee safety. Clearly record the resolution process and any actions taken for accountability and future reference. OPERATIONAL DEFINITIONS This is a list of common terms that are used throughout these worksheets. These terms may be in the title, resources or additional considerations. •American Health Information Management Association (AHIMA) o Professional organization with resources on privacy, coding and information governance. •Board of Certification (BOC) o The national health care credentialing organization for Certified ATs whom is responsible for upholding standards of professional practice for ATs •Center for Disease Control (CDC) o U.S. federal agency focused on protecting public health by preventing and controlling diseases, injuries and disabilities. •US Food and Drug Administration (FDA) o Learn how to dispose of unused or expired drugs •HIPAA (Health Insurance Portability and Accountability Act) o U.S. federal law that sets standards for protecting patient health information (PHI). •HITECH Act (Health Information Technology for Economic and Clinical Health Act) o Strengthens HIPAA rules, especially for electronic health records. •International Labour Organization (ILO) ƈ The International Labour Organization (ILO) is devoted to promoting social justice and internationally recognized human and labor rights, pursuing its founding mission that social justice is essential to universal and lasting peace. •Joint Commission on Accreditation of Healthcare Organizations (JCAHO) o Accredits health care facilities by setting standards for patient safety and quality health care. •Korey Stringer Institute (KSI) o Mission of preventing sudden death in sport and physical activity through consultations, advocacy, education, research, athlete testing and mass- market outreach. •MyHealthEData Initiative o Helps patients understand their rights to access and protect their health data. BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENTBOCATC.ORG 7 Policy Mapping and Needs Identification •National Athletic Trainers’ Association (NATA) o The NATA is the professional membership association for Certified ATs and others who support the athletic training profession •National Institute of Standards and Technology (NIST) o Publishes cybersecurity and PHI protection standards. •Office for Civil Rights (OCR) – U.S. Department of Health and Human Services o Enforces HIPAA and handles privacy complaints. •Occupational Safety and Health Administration (OSHA) o OSHA is part of the United States Department of Labor. The administrator for OSHA is the Assistant Secretary of Labor for Occupational Safety and Health. •US Department of Labor Office of Workers’ Compensation Programs (OWCP) o The U.S. Department of Labor’s Office of Workers’ Compensation Programs (OWCP) administers four major disability compensation programs which provides to federal workers (or their dependents) and other specific groups who are injured at work or acquire an occupational disease. •World Health Organization (WHO) o The United Nations agency working to promote health, keep the world safe and serve the vulnerable. BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENTBOCATC.ORG 8 It is important to recognize employee safety and formalize protocols and plans designed to minimize risks and ensure there is a safe working environment. These policies could include, but are not limited to, prevention measures, protocols for emergencies, compliance regulations, working conditions and safety procedures. The AT should work with administration and organizational units to ensure employee safety is a top priority and align protocols with any institutional or organizational policies. These might include OSHA guidelines or required policies and procedures for maintaining safety standards for practice. This template is used to serve as guidance for areas to consider related to employee safety. Certain practice settings (e.g., public safety, military) may require an elevated level of resources, training or procedures. The employee may need to coordinate with Safety Officers, Range Officers or Operations Unit. 1.Bloodborne Pathogen (BBP) Exposure Control Plan Exists Need Notes: Suggested Resources: •CDC o CDC Guidelines for bloodborne pathogens o CDC PPE Homepage •OSHA o OSHA Guidelines for bloodborne pathogens o Infectious Diseases o OSHA PPE Homepage •WHO - WHO PPE Homepage Additional Considerations: •Emergency BBP procedures to exposure •Maintaining records of employee training for BBP •Ensure compliance with all employers, local, state and federal policies and/or regulations •Alignment with contaminated materials disposal policy •Available handwashing stations with soap •Available sharps containers for tools used in facility •PPE: requirements, logistics, maintenance and disposal Employee Safety BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENTBOCATC.ORG 9 Employee Safety 2.Hazard Communication (Chemical Safety/SDS) Exists Need Notes: Suggested Resources: •OSHA - OSHA Chemical Hazards and Toxic Substances •Safety Data Sheet Database - Safety Data Sheet Search •WHO - WHO Chemical safety homepage Additional Considerations: •Hydrotherapy pool/tub disinfectant and cleaning supplies •Storage, transport and transfer of chemical supply policy •Ensure compliance with all employers, local, state and federal policies and/or regulations •Ordering and catalog of chemicals policies •Appropriate documentation form(s) •Determine process for containment •Create decontamination procedures •Ensure appropriate supplies and equipment for labeling, storage, tracking, monitoring and containmentNext >