Minnesota Department of Corrections
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.
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.
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.
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.
REFERENCES: ACA Standards 4-4381, 4-4382, 4-4361, and 1-ABC-4E-41
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.
Deputy Commissioner, Facility Services