A Much Utilized Tool
Physicians' standing orders are used in numerous clinical settings and in the care and treatment of almost every patient population. They are routinely used by nurses, for example, to evaluate and treat children in summer camp, and to facilitate the provision of care in the emergency department to patients with chest pain. Standing orders assist hospice nurses in rendering needed palliative measures to their patients and are routinely used to inform nursing homes regarding when to screen residents for tuberculosis and when to vaccinate them for influenza. They are even used by "wilderness" teams in the treatment of injured people in remote locations.
Considering the extensive use of standing orders by nurses in providing patient care, it would be beneficial to examine the legal foundation of these often-employed tools.
Physicians' vs Standing Orders
It is important to understand the difference between "physicians' orders" and "standing orders." The most obvious difference is that physicians' orders are generally the instructions of a physician for the care of an individual patient. Usually, a physician examines and assesses the patient before prescribing the orders. As used in this article, standing orders are defined as orders developed for the use of certain patient populations that present with particular needs or symptoms in the absence of a physician examination and assessment.
A standing order can be further defined as written instructions or procedures prepared by a physician and designed for a patient population with specific diseases, disorders, health problems or symptoms. Such instructions delineate under what conditions and circumstances action or treatment should be instituted. Generally, the standing orders are developed and approved by the physician who is responsible for the delivery of medical care covered by the orders. Additionally, if the standing orders are used in a facility, they also are approved by the facility's medical executive committee or a committee with oversight of the department or unit where the standing orders will be applied.
The legitimacy for standing orders rests in state licensure laws for physicians and nurses. Physician state licensure laws generally provide that physicians may delegate certain duties, tasks and responsibilities to licensed individuals whose license, training, education or experience qualifies them to perform the duties. The delegated acts or functions thus are technically deemed to fall within the scope of the physician's professional practice, but when the functions are delegated, they may be performed by another, so long as they are safely performed under the physician's direction.
The crucial inquiry for the nurse to whom the task is delegated is whether the nurse's state practice act permits the performance of the delegated task. Most state practice acts delineate the scope of the nurse's practice, including when the nurse functions as an advanced practitioner such as a nurse midwife or certified registered nurse practitioner. Many state practice acts describe the scope of practice for the advanced practice nurse with greater particularity than for that of the registered nurse.
It is always a good idea to review your state's nurse practice act or to contact your state board of nursing if you have any questions as to whether a delegated task falls within the scope of your license.
Although there are no precise and definitive requirements for standing orders, at a minimum they must be in writing, signed by the physician and dated. Generally, it also would be prudent for standing orders to:
identify the patient population to be treated according to the standing orders
specify which acts require any particular level of experience, training, education or licensure
specify those who may perform the actions required under the standing orders
delineate under what circumstances the prescribed acts are to be performed
specify the scope of supervision required for performance of standing orders (e.g., immediate or direct supervision of a physician or supervision available by phone contact)
set forth any specialized circumstances under which a person implementing the standing orders is to immediately communicate with the patient's physician concerning the patient's condition
state any limitations on the practice setting, if any, in which the standing orders may or may not be performed
provide for a method of maintaining a written record of those authorized to perform the duties prescribed in the standing orders
establish a method for initial and continuing evaluation of the competence of those authorized to function pursuant to the standing orders
specify patient record-keeping requirements, which should provide for accurate and detailed information regarding patient visits or encounters that utilize the standing orders
provide for a method of periodic review of the standing orders
Benefits, Liabilities of Standing Orders
The use of standing orders can, among other things, promote consistent treatment in patients with similar symptoms and help with patient assessment by guiding nurses through particular steps as they implement the treatment protocol specified in the standing order.
Standing orders often represent the "collective wisdom" gained by practitioners through previous patient experiences, thereby allowing patients to reap the benefits of these prior encounters.
Additionally, standing orders can protect nurses from charges of practicing without a medical license and, if malpractice litigation arises later, they can assist in reconstructing the treatment rendered. Of course, the caveat to these last two benefits is the presumption that the nurse implements the standing order as prescribed and stays within the confines of the delegation outlined in the standing order.
Because the legal foundation for standing orders rests on the permitted delegation of a physician's task to the nurse, the nurse must be cautious not to go beyond that.
Any questions about permitted actions under the standing orders are best addressed and clarified with the physician well before being called upon to implement the standing order. Further, if the nurse is confronted with an unexpected patient symptom, complication or other situation while implementing the standing order that requires physician assessment and intervention, then the nurse should use professional judgment and contact the patient's physician.
Similarly, the nurse should be sure to faithfully implement the standing orders that exist in the practice setting. For instance, if the nurse works in a unit with a standing order to check a patient and record vital signs at definite times, or to use certain monitoring equipment on all patients admitted to the unit, then she should not become complacent about their implementation.
Nurses have faced malpractice lawsuits for not following standing orders. For example, a nurse in California was sued when she did not, in a timely manner, follow a standing order to place on a continuous fetal monitor a patient who was in labor and admitted to the maternity unit. The baby was born with severe brain damage and the jury determined that the nurse's failure to use the fetal monitor as ordered fell outside the acceptable standard of nursing care.
If a nurse determines not to follow a standing order, she should carefully document why, as well as the circumstances that support the deviation from the standing order.
Standing orders are a vital and worthwhile tool in the care and treatment of many patients. To remain effective, they must fit within the parameters of nursing licensure laws and be implemented by nurses as prescribed.
Renee H. Martin, a registered nurse and attorney, is a health care associate with Reed Smith, a Philadelphia law firm.