Public Health Law Map - Beta 5 - Medical and Public Health Law Site

generally unnecessary in a physician protocol and not proper in a protocol intended
for NPPs. The classic example of a group of teaching protocols is the Washington
Manual of Medical Therapeutics, often called the “intern’s brain.” The entries in this
manual include a general definition of the condition and a list of other possible
causes of the patient’s problems. It then explains how to treat the patient, with
reasons for some of the recommendations. Medical students use this source to learn
about basic treatments. Residents use it as a treatment guide and for help in solving
unfamiliar problems. Established physicians consult it when caring for patients with
a problem they have not treated recently or for which treatment standards have
changed. Each would learn from the protocols and use them according to their level
of training and licensure.
8. Physician’s Orders
The most common way of delegating authority is to write an order in a hospital chart
or otherwise formally record orders for NPPs. The physician may write the order in
person, or a nurse may enter it in the chart at the physician’s direction. Formal orders
are valuable for clarifying the delegation of authority in the hospital setting, though
they are less commonly used in private offices.
Standing orders, which include protocols, are a special case of written physician’s
orders. A standing order is an order conditioned upon the occurrence of certain
clinical events. The important characteristic of a standing order is that all the patients
who meet the criteria for the order receive the same treatment. A common use of
standing orders is in public health clinics that treat specific diseases. A venereal
disease control program will use the CDC protocols for antibiotic dosages. Once the
specific venereal disease is identified, the nurse administers the antibiotics as
specified by the CDC protocol and authorized by the physician directing the clinic.
In this situation, the CDC protocol is a standing order from the medical director, and
the conditional event is the diagnosis of a specific venereal disease.
It is important to differentiate standing orders from preprinted orders: orders that the
physician uses repeatedly and has photocopied to save the trouble and potential
errors of rewriting each time they are used. Although the orders are the same for all
patients, they are not standing orders because they are not conditional. The physician,
not the nurse, determines whether the printed orders will be used in a given case.
Unlike a standing order, until the physician incorporates the printed order into the
chart, the nurse cannot initiate treatment. Preprinted orders are a useful tool, but they
can lead to problems if a patient requires a variation in the usual printed order. These
variations must be carefully marked on the orders and the nursing staff notified that
the printed order has been modified.
Direct orders are voice orders that are given directly to NPPs. Sometimes these
orders are documented in the medical records, but usually they are carried out at once
and not recorded. For example, when a surgeon directs the operating room nurse
assisting in a procedure, some of the surgeon’s orders will be documented, but most
will not. Documenting the individual orders is not a problem in this situation because
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