Can Medical Assistants and LVNs Follow Standing Orders and Protocols?

Carolyn Buppert, MSN, JD

Disclosures

December 26, 2013

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Question

I am a California nurse, working at a facility which has been "de-skilling" -- using more medical assistants and licensed vocational nurses. Can these workers follow standing orders and protocols?

Response from Carolyn Buppert, MSN, JD
Healthcare attorney, Boulder, Colorado

What Can Less Skilled Staff Do?

A nurse from California who works in an outpatient setting expresses concern about staff duties and responsibilities at her facility. Registered nurses are being replaced by licensed vocational nurses (LVNs) and medical assistants (MAs). Her questions pertain to the use of standing orders and protocols by these less skilled providers.

The first question has to do with ordering laboratory tests for a specified population of patients, as in the following example:

There is a standing order for labs -- let's say every 3 months -- for a population of patients with diabetes. The physicians and the facility have agreed on this, and there is a policy about it. Can a MA order these labs without having the provider sign the order on the electronic record? We are told that they can, because the MA is not making a decision to order but is only transmitting the order on behalf of the provider. The order is not sent to or signed electronically by the provider.

The second question pertains to dosing protocols for allergy shots.

In an allergy department, antigen shots are given on an escalating dose schedule according to a protocol, depending on the patient's reported reaction or lack of reaction. There is a table with the escalating dose amounts on the protocol. We are told that as long as the LVN asks and documents the pertinent negatives and follows the protocol, the LVN can escalate the dose according to protocol and administer it without consulting with the provider.

This suggests (to me) that the LVN is assessing and developing a plan of care. It was my understanding that LVNs may gather data, but then a registered nurse (RN) or physician must make an assessment and determine the plan of care. Furthermore, if the latter is true, must the RN or physician document the assessment and plan of care in the medical record after receiving the data, or can the LVN proceed independently?

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