Carolyn Buppert, NP, JD


December 07, 2012

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Standing orders for colonoscopy preps are routinely ordered by the registered nurses under a physician's name. Is this legal?

Response from Carolyn Buppert, NP, JD
Attorney, Law Office of Carolyn Buppert PC, Bethesda, Maryland

This question comes from a nurse who has completed advanced practice education and certification but does not have prescriptive authority.

The use of standing orders in gastroenterology practice may be legal, but the words "registered nurses" (RNs) and "ordering," used together, is bothersome, so I cannot approve this process without knowing more. If nurses are "ordering" medications, that is inherently illegal. Here are my thoughts.

If you don't have prescriptive authority, then your scope of practice with respect to prescribing is the same as that of an RN: That is, you don't have the authority to prescribe or order medications. So, I will discuss how standing orders should work for RNs.

A nurse may carry out physician orders or orders from another authorized prescriber. A "standing order" is a prewritten medication order and specific instructions from the licensed independent practitioner to administer a medication to a person in clearly defined circumstances.[1] If a gastroenterologist sets up standing orders for patients about to undergo colonoscopy, a nurse could carry them out.

How this would work in the gastrointestinal office setting or hospital isn't clear to me. I doubt that the nurses are actually administering the colonoscopy prep. Are the nurses dispensing the prep medications? Or are the nurses calling the prescription into the pharmacy? If they are dispensing, that is a pharmacy function, and a nurse should consult the state's pharmacy regulations to determine whether he or she is inappropriately dispensing.

If nurses are calling prescriptions into pharmacies under a physician-employer's name, that is legal, if the physician has authorized the nurse to do so and there is an order for the medication in the patient's chart. If there is a written standing order in the office or hospital chart, put there because the practice has a policy that all patients who are scheduled for colonoscopy have these orders, then it would be legal for a nurse to call the prescription into the pharmacy. The nurse is not ordering the medication; the physician is. The nurse is acting as the physician's stand-in when calling in the prescription that the physician has written, because the physician has delegated that function to the nurse.

Note that standing orders are not legal in all states. For example, in New York, nurses may immunize, provide and administer antianaphylactic agents, and give purified protein derivative (PPD) tests and HIV tests under standing orders; however, other standing orders are not legal.[2]

The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) discourage standing orders but do not prohibit them, if they promote timely and necessary care. Here is CMS's position: "The use of standing orders must be documented as an order in the patient's medical record and signed by the practitioner responsible for the care of the patient, but the timing of such documentation should not be a barrier to effective emergency response, timely and necessary care, or other patient safety advances."[3]

The bottom line for nurses is that they cannot order or prescribe medications, and if they are transmitting orders written by a physician or other authorized prescriber, there must be a written order from the authorized prescriber to back them up.