This is an excerpt of UNC Health’s recently revised policy on standing orders.[1] “This is a regulatory topic that we have continued to work on year over year,” said Patrick Kennedy, executive director of hospital compliance. “In my opinion, it is a relatively easy standard to understand yet seen by some as challenging to implement, especially in a dynamic setting like an academic medical center.” Contact him at patrick.kennedy@unchealth.unc.edu.
III. Policy
Minimum Requirements for Standing Orders
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Must be developed and approved through multi-disciplinary Committee(s), which must include, but is not limited to, medical staff leadership, chief nursing officer or designated nursing executive, and pharmacy leadership.
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A standing order that contains medications should be reviewed and approved by a local network entity’s Standing Orders Committee or, in the absence of such, its Pharmacy and Therapeutics Committee or other defined clinical committee with Pharmacy representation.
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Must be consistent with federal and North Carolina regulations, guidelines, and must be evidence-based practices for providing patient care.
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Must define staff that may initiate the standing order (e.g., nurse) within their specific scope of practice and well-defined instructions or clinical situations for when the order can be initiated.
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Under no circumstances shall a standing order be initiated that requires non-LIP (licensed independent practitioner) staff to enter patient care orders by making clinical judgments or decisions outside of their scope of practice.
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When requesting review and approval of a proposed standing order, information submitted to the Committee should include, but is not limited to:
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Reason and clinical condition or situation in which the standing order will be used, to include information related to evidence-based practice, but should not include actual citations or references;
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Staff that can implement the standing order;
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Clinical assessment criteria to include the type of patients for which the standing order applies;
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Criteria or circumstances for when the LIP is to be consulted;
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Plan of care to be carried out by the non-LIP who is initiating the standing order, including: medical/medication treatment regiment, nursing actions, and follow-up monitoring requirements;
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Request for authentication by the LIP responsible for the patient’s care or, if no co-signature is required, then an explanation as to why one is not required; and
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Date the standing order was initially developed or last reviewed by the Committee.
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Must be medically appropriate for a patient whom the order is being applied to.
