Physician Orders

General Guidelines

According to the Nursing Practice Act (Chapter 335 RSMo) the scope of practice of the professional nurse includes administration of medications and treatments as prescribed by a person licensed by a state regulatory board to prescribe medications and treatments (physician). Therefore, the Missouri Department of Health and Senior Services (DHSS) recommends physician orders should be obtained for administration of all medications and treatments.

Telephone orders for medical treatment and medications are to be taken and recorded only by a licensed nurse. It is the right and responsibility of the nurse to question orders the nurse deems inappropriate and to verify the validity of any order. Telephone orders should be sent to the physician for signature within 24 hours. If not returned within 72 hours, the physician should be contacted. If not returned in the next 72 hours, notify physician of orders being discontinued. One way to avoid the problem of telephone orders is to have a signed order FAXED.

Registered professional nurse or licensed professional nurse under the direction of a registered professional nurse may carry out orders from a physician licensed by any state regulatory board to prescribe medications and treatments.

A physician order is not needed for a registered nurse to perform independent nursing acts, as long as the nurse defensibly has the required specialized education, judgment and skill.

The Missouri State Board of Nursing has issued an opinion (March, 2000) that registered professional nurses and licensed professional nurses under the direction of registered professional nurses may perform finger sticks and heel sticks for assessment purposes without an order from a physician. This opinion means that obtaining a blood sample using a finger stick or heel stick is considered an assessment act and is included in the specialized education, judgment and skill of the registered professional nurse identified in the Nursing Practice Act. However, determining what should be done based on the sample, including treatment decisions, interventions and follow-up, is the province of the physician; therefore, appropriate standing orders, protocols or collaborative practice agreement should be in place for such actions.

Standing Orders
Standing orders are appropriately used in a local public health agency for some services (e.g., immunizations, STD screening, TB testing).

DHSS recommends that, at a minimum, standing orders should include:

• The geographic area to be served by the public health agency (XY County or YZ City);
• Process for the review of services by the physician and nurse (Evaluation of the standing orders protocols and implementation should be on a predetermined time schedule. The scope of the evaluation will vary widely, dependent upon the services to be provided);
• Full name of the patient or group of individuals who will receive treatment such as, “persons presenting themselves for immunizations” or “persons presenting themselves for TB testing;”
• Date the order is written by the physician;
• The name of the test, medication or treatment to be administered;
• Dosage of the drug or reference to established guidelines such as CDC, DHSS or Advisory Committee on Immunization Practices (ACIP);
• Method of administration of medication or treatment;
• Signature of the physician.

All standing orders should be reviewed and revised as needed, or at least once a year.

All staff who carry out standing orders should review the orders and document that the review has occurred.

Each agency should have policies and procedures to implement all standing orders, including assessment of the patient and emergency treatment. See Section 300.05 for guidelines for developing policies and procedures.

References
Missouri State Board of Nursing. (1996), Physician Orders/Relaying of Orders Information Packet.

Missouri State Board of Nursing. (1998), Registered Professional Nurse/Advanced Practice Nurse Information Packet

Chapter 334.04, RSMo, 1994

4CSR 200-4.200.

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