questions on protocols and standing orders

muffie, RN · Oct 17, 2006

we require our protocols and standing orders to be signed

we have presigned medical directives

Home Health Columnist / Guide · Oct 17, 2006

Physicians do need to sign standing orders or protocals. Protocals are usually kept in a binder at the nursing station for reference by clinical staff.

Standing orders often are developed for a specific doctors patients major diagnosis that he treats. Orders are preprinted on a form. Doctor will sign form at the bottom and send to unit as orders for each patient. Occassionly doctor will edit orders to tailor to individual patients needs by writing D/C next to order.

For example Orthopedic orders post hip replacement:

1. Follow hip replacement protocal.

2. Administer IV one liter DrLR @ 80 cc hr x 24 hours. Change to capped IV lock and Flush with 3 cc NSS IV Q shift.

3. Administer Lovenox ____mg SQ Q 12 hours.

(Doc will write in specific dose based on pts weight)

4. Apply compression boots/ SCD.

5.. Administer Morphine Sulfate 2 mg IV Q 4 hours via PCA pump. May have Morphine 1 mg IV Q 2hrs bolus prn.

6. Colace 1 tab daily PO.

7. Ambulate with rolling walker WBAT post op day 1.

8. Incentive Spirometry Q 2hrs while awake.

Dr Luke Skywalker MD 10/16/06

eiccdnursingstudent · Oct 17, 2006

Physicians do need to sign standing orders or protocals. Protocals are usually kept in a binder at the nursing station for reference by clinical staff.
Standing orders often are developed for a specific doctors patients major diagnosis that he treats. Orders are preprinted on a form. Doctor will sign form at the bottom and send to unit as orders for each patient. Occassionly doctor will edit orders to tailor to individual patients needs by writing D/C next to order.
For example Orthopedic orders post hip replacement:
1. Follow hip replacement protocal.
2. Administer IV one liter DrLR @ 80 cc hr x 24 hours. Change to capped IV lock and Flush with 3 cc NSS IV Q shift.
3. Administer Lovenox ____mg SQ Q 12 hours.
(Doc will write in specific dose based on pts weight)
4. Apply compression boots/ SCD.
5.. Administer Morphine Sulfate 2 mg IV Q 4 hours via PCA pump. May have Morphine 1 mg IV Q 2hrs bolus prn.
6. Colace 1 tab daily PO.
7. Ambulate with rolling walker WBAT post op day 1.
8. Incentive Spirometry Q 2hrs while awake.
Dr Luke Skywalker MD 10/16/06

I understand what you are saying and they are a set of guideline that nurses can refer to. But then you said the Dr. signs the bottom of them when he uses them for a patient (whether or not he changes them). But he would still have to sign them for the nurse to administer meds right? I was just wondering, because if he didn't sign it and you administered the meds, who would be responsible if something happened to the patient. It wouldn't be the doctor because he didn't sign it (prescribe it) right? I was under the impression that you couldn't administrate any meds without a physicians written signature, even telephone orders need to be signed within 24 hrs. I guess that I am not getting it. Could you please explain more to me. Thank You for you help

ginger58, ASN, RN · Oct 17, 2006

If we take a telephone order from a doc we can go a head and give the med but he has to sign the order in 24 hours.

An order set, such as described by Karen, would have the orders with the blanks filled in and choices made and would be signed by the doc.

In an emergency on the floor you would of course take a phone/verbal order and give the drug.

Creamsoda, ASN, RN · Oct 17, 2006

We have protocols for kcl and MGSO4, and hypoglycemia. Unless it is stated to not follow the protocol, we replace according to protocol and there is no actual signature by the doc.

Cher

perfectbluebuildings, BSN, RN · Oct 17, 2006

We have (very specific) standing orders from the hospitalists for Tylenol for kids over a certain age, for Mylicon, and when to call vs. not call about restarting an IV during the night, and other things I don't remember at the moment. They are on the computer system and we can look them up and copy verbatim to the chart, writing "per standing orders of XX service" and signing. The MD then signs within 24hrs like on phone or verbal orders, but we can go ahead and give the meds at the time we write the protocol/standing order as soon as available from Pharmacy.

Edited to add: These are different (at my hospital) from a generalized protocol sheet that the doctor uses a copy of to admit a patient, and has to fill out certain blanks in it and it is added to the chart as admit orders, saves them time instead of writing all the usual orders out each time but must be signed just as if they write out the orders.

I hope I make sense but I don't think I am, sorry.

Antikigirl, ASN, RN · Oct 17, 2006

The above posters are totally on it! The wierd area is the telephone orders where your facility policy has a say. For me, and basically everyone I have heard from...the MD has 24 hours to sign a telephone order..and our pharmacy will not despence meds after that so it is a nice checks and balances if you don't have the time to go back charting to find out the exact time of order....

If you have a doubt...there is a very simple solution..call the prescribing MD! Yeah they may not like you for it, but that is a good thing for pts and your own CYA...opps I mean peace of mind ....