Abstract
Implementation of the Universal Protocol in an office-based gastrointestinal procedure unit is driven by documentation scripts in the electronic medical record. Designing templates for procedure documentation guides the nursing staff through the protocol and ensures compliance. Using a 3-phase plan ensures adherence to the Universal Protocol, the right patient has the right procedure, and the right specimens are marked for that patient. This protocol does not just take place before the procedure. It starts when the patient enters the unit and extends until the patient is discharged home.