Minnesota Department of Corrections


Division Directive:                 500.040           Title: Standing Orders

Issue Date:                             6/17/14

Effective Date:                      7/1/14


AUTHORITY:           Policy 500.010, “Health Services”

Prison Rape Elimination Act (PREA), 28 C.F.R. §115 (2012)


PURPOSE:    To standardize basic nursing care utilizing physicians’ standing orders for medications and treatments for use in specific medical conditions.


APPLICABILITY:    Minnesota Department of Corrections (DOC); health services


DIRECTIVE: The department maintains physician’s standing orders for use in specific medical conditions.



Physician standing orders – physician ordered directions that correspond to specific health conditions requiring a course of action that may include medications, treatments, lab work, immunizations, sexual assault, or any other interventions as indicated.


Pharmaceutical and therapeutic (P&T) committee – a formal committee consisting of DOC representatives: a psychiatrist, medical director, behavioral health director, nursing director, and contracted vendor representatives: the medical director, pharmacist, regional director, and other participants as invited.  The purpose of the committee is to review, revise, and approve the formulary and prescribing practices, develop and/or approve treatment protocols, establish therapeutic substitutions, perform drug utilization reviews, and resolve issues involving the delivery and dispensing of medications.



A.        The P&T committee:

1.         Approves all standing orders prior to implementation;

2.         Reviews standing orders at least annually, and revises if indicated; and

3.         Signs all standing orders (medical director) prior to implementation and at least annually.


B.        Health services staff provides nursing care for specific conditions in accordance with approved standing orders and documents a progress note indicating the assessment, plan of care, and standing orders that were implemented.


C.        The electronic medication administration record (eMAR) is used to document standing order medications administered by nursing or other trained staff.



A.        The review of standing orders is documented in the P&T committee minutes located in central office health services.


B.        Documentation of standing order implementation is located in the medical record.


REVIEW:       Annually


REFERENCES:         ACA Standards 4-4382 4-4361, and 1-ABC-4E-41

Policy 500.200, “Management of Medications”

Division Directive 500.201, “Medication Administration”

Division Directive 500.205, “Implementation of Practitioner Orders”


SUPERSESSION:     Policy 500.040, “Standing Orders/Nursing Protocol Manuals,” 11/5/13.

All facility policies, memos, or other communications whether verbal, written, or transmitted by electronic means regarding this topic.





Deputy Commissioner, Facility Services