Minnesota Department of Corrections

 

Division Directive:                500.040           Title: Standing Orders

Issue Date:                             7/5/16

Effective Date:                      7/19/16

 

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.  Standing orders may not be extended or renewed by a registered nurse a consecutive time.  A practitioner must be notified for further evaluation and provide a medical order for continued use if this is deemed necessary.

 

DEFINITIONS:

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.

 

PROCEDURES:

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.

4.         Document in the P&T committee minutes the review of standing orders and retain the minutes in central office health services.

 

B.        Only registered nurse may authorize the initiation of a standing order.

 

C.        Registered nurses must document in the progress notes an assessment, including rationale for initiating a standing order.

 

D         Licensed practical nurses or other trained staff may administer standing orders previously initiated by a registered nurse.

 

E.         All standing-order medications must be given Direct Observed Therapy (DOT), administered on a dose-by-dose basis.

 

INTERNAL CONTROLS:

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

 

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

 

REVIEW:      Annually

 

REFERENCES:        ACA Standards 4-4381, 4-4382, 4-4361, and 1-ABC-4E-41

Policy 500.200, “Management of Medications”

Division Directive 500.201, “Medication Administration and Monitoring”

 

SUPERSESSION:     Policy 500.040, “Standing Orders/Nursing Protocol Manuals,” 7/1/14.

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

 

ATTACHMENTS:    None

 

 

/s/

Deputy Commissioner, Facility Services