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.



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.


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.






Deputy Commissioner, Facility Services