Guidelines (Protocol/Standing Orders) for Ordering Preoperative Tests

In April 2004, the Board responded to opinion requests on the roles of nurses in ordering preoperative tests using “protocols/standing orders,” including the following:

1. A request on the role of registered nurses in utilizing a facility’s established “Anesthesia Preoperative Testing Protocol Policy” and ”Preop Orders” to order diagnostic tests for patients, based on the patient’s self-reported medical history and preanesthetic assessment.
   
   It was the advisory opinion of the Board that it is within the jurisdiction of a health care facility to establish policy and procedure governing preadmission/preoperative patient diagnostic testing.
   
   Further, it was the opinion of the Board that it is within the scope of registered nursing practice for the registered nurse, qualified by education and demonstrated competency, to implement a medically approved protocol for preadmission/preoperative diagnostic testing such as the protocol included in the request.
   
   
2. A request on the role of registered nurse in utilizing “standing orders,” “physician protocols,” and “routine orders” for patients who are seen by the nurse for preadmission or preoperative evaluation.  A sample of a facility’s “Anesthesia-Routine Orders” was included in the request and specific questions regarding its use were asked.
   
   The Board advised that the terms ”protocol,” and  “standing or routine orders,” are not defined in the Kentucky Nursing Laws (KRS Chapter 314) and are often used differently in various health care settings.  The terms may refer to orders approved by both the medical and nursing staff including patient care orders that are applied to all patients in a given situation, or specific pre-printed orders of a given physician/ARNP.  The determination as to when and how “protocols and standing/routine orders” may be implemented by nurses is a matter for internal deliberation by the health care facility.  The formulation of policies and procedures on the use of protocols and standing/routine orders is a decision of the employer, predicated on the experience and educational preparation of the licensees employed to implement the procedures, as well as upon nursing and medical standards of practice.

It was the advisory opinion of the Board that KRS Chapter 314 does not authorize a registered nurse or licensed practical nurse to render medical diagnosis or to prescribe a medical plan of care.  Qualified advanced registered nurse practitioners however are authorized to perform these acts.

Qualified registered nurses may implement physician/ARNP standing/routine orders, including administration of medications, for treatment of select signs and/or symptoms following nursing assessment and nursing diagnosis.  Standing orders should be written to reflect treatment of signs and symptoms, rather than a medical diagnosis and should include parameters for the nurse to refer and consult the physician/ARNP.  In addition, the standing orders should be officially approved by the facility medical staff, or approved by the prescriber for the individual patient.

Update:  In June 2004, the Board approved revisions to Advisory Opinion Statement #14 Roles of Nurses in the Implementation of Patient Care Orders [PDF Format - 35k] to include information on the use of protocols and standing/routine orders.