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Policy Development LibGuide: Resources to support Prompt Guideline Development

Writing Clinical Procedures

Please refer to the following Libguides on the navigation bar to assist with updating or creating a Prompt guideline

Follow the boxes in numbered sequence; or refer to a specific box in relation to the stage of your Prompt guideline development

 The information in this guide has been approved by the Clinical Education & Clinical Governance departments.

1. Adapt an existing procedure from a high quality external resource

A high quality external resource can be identified as one of the following, these websites have already gone through stringent appraisal and methodology processes.

Clinical Guidelines  are evidence based statements that include recommendations intended to optimise patient care and assist health care practitioners to make decisions about appropriate health care for specific clinical circumstances.  

Start with Australian based guidelines such as Safer Care Victoria & Choosing Wisely which provide a broader range of topics or choose a more specific resources e.g updating oncology policies try Eviq or for stroke policies refer to Stroke Foundation's Living stroke Guidelines.

For a full list of Australian-based Living Guidelines click here at the Australian Living Evidence Consortium page.

UpToDate now has links to guidelines, simply search for a topic and click on the Society Guidelines link in the topic contents listing.

Evidence Based Resources

Up To Date  - UpToDate is an evidence-based, physician-authored clinical decision support resource that assists clinicians with point-of-care decisions. UpToDate covers 25 medical specialties with over 10,500 topic reviews, each of which covers multiple clinical questions.  Additionally, UpToDate includes graphics, patient education, clinical calculators, and a drug database. 

Cochrane - The Cochrane Library is a collection of five databases that contain different types of high-quality, independent evidence  (Systematic reviews, Trials, RCT's).  Access to Cochrane is free via funding by the Australian Government.

How do I appraise a guideline?

Please refer to the Clinical Practice Guidelines Subject Guide and select the Evaluating Guidelines tab, which links out to checklists Agree-II

2. Adapt an existing procedure from other hospital Prompt Guidelines

What is Prompt?

Prompt stores policies and procedures of other 100 Victorian health services, who subscribe to this software

Where do I access Prompt?

Prompt is accessible from Cabinet main page and other locations inside the Cabrini Intranet (Cabinet)

How do I view other hospitals Prompt documents?

To view another health organisation's on Prompt you are required to have your own personal login.

Can I access Prompt from offsite?

Y​​​es you can.

Please contact to register for remote access/personal registration

Important - A similar or same topic of an existing procedure produced by another health service doesn't mean it is necessarily of high quality.

Note the following in the health services documents

  • Check the date it was last reviewed (Has the policy been reviewed in the last 12 months)
  • Is the content applicable to local Cabrini hospitals processes and governance structures.
  • Discuss the information with the relevant Clinical Governance Standard Committee for approval.  (Refer to box 4)

3. Developing a procedure from its inception

If you cannot find an existing high quality procedure to adapt or there are no guidelines, then you need to develop your procedure by searching for original studies to provide evidence to write the policy.

Listed below are some referring guides to assist with your search.

  • Information Skills Competencies - Refer to the Information Skills Libguide
  • Search Medline via OVID Medline or PubMed for original studies
  • Search UptoDate or Cochrane for latest evidence summaries.
  • Search EMBASE or CINAHL via affiliated universities, Cabrini no longer subscribes to these databases (January, 2022)
  • Search strategies to use which are aligned with the NSQHS Standards.  Refer to the NSQHS Libguide
  • Book a consultation with a librarian for further help with your literature searching skills or developing a search strategy

The library service offers staff a literature search service 

  • Request a Literature Search - Cabrini Health staff may request literature searches for Cabrini health policy/protocol development on their behalf.

4. Expert Input / Professional Knowledge

For some topics there may be little evidence from clinical trials, or the evidence may be weak or contradictory.  In these instances health professionals can tap into knowledge, experience and judgement of health professionals, topic experts and consumers to make consensus recommendations.

 Utilise the Cabrini Clinical Safety and Quality Stands Committees for facilitating discussion and consensus on the information sourced.

5. Referencing

Cabrini has adopted the APA style for referencing of Prompt policies and guidelines.

Please refer to the Referencing Guide for examples of various formats including-

  • NSQHS Standards
  • Government Websites
  • Journal Articles


Some of the content was adapted with permission from the Barwon Health Libguide. Clinical Procedure Development..