Policy:                                    500.040

Title:                                      Standing Orders

Effective Date:                      1/2/18


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



Physician standing orders – physician-ordered directions that correspond to specific health conditions (including conditions related to sexual assault) requiring a course of action that may include medications, treatments, lab work, immunizations, 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, and nursing director; and contracted vendor representatives: the medical director, pharmacist, and 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 department maintains physician’s standing orders for use in specific medical conditions.  Standing orders are developed and implemented as outlined in these procedures.


B.        The pharmaceutical and therapeutic (P&T) committee:

1.         Approves all standing orders prior to implementation;

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

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

4.         Documents in the P&T committee minutes the review of standing orders and retains the minutes in central office health services according to the approved retention schedule.


C.        Only registered nurses may authorize the initiation of a standing order.


D.        Registered nurses must document in the progress notes an assessment, including the rationale for initiating a standing order.  Documentation of standing order implementation is retained in the medical record.


E.         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.


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


G.        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, which are retained in central office health services according to the approved retention schedule.


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


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


REFERENCES:        Policy 500.010, “Health Services”

Policy 500.200, “Management of Medications”

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


REPLACES:              Policy 500.040, “Standing Orders/Nursing Protocol Manuals,” 7/9/16.

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






Deputy Commissioner, Facility Services

Deputy Commissioner, Community Services

Assistant Commissioner, Facility Services

Assistant Commissioner, Operations Support