Health Information Management

Patient care orders/protocols: What do the regulations say?

HIM-HIPAA Insider, April 20, 2015

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At HCPro's Accreditation Specialist Boot Camp, we continue to receive questions about standing orders, protocols, and verbal/telephone orders. With spring upon us, I thought a fresh look at these topics would be in order (no pun intended). Let's try to dispel the myths and go straight to what the regulations say and what is best practice to meet them.

 

Standing orders refer to orders usually formulated by the professional members of departments in the hospital or healthcare facility that prescribe the actions to be taken in caring for patients related to specific conditions or procedures. They include dosage, route, and frequency of drug administration as well as administration of therapeutic procedures. Order sets are similar to standing orders and are standardized lists of orders for a specific diagnosis/procedure. The terms are often used interchangeably. Standing orders and order sets are often used in the intensive care unit, cardiac care units, and EDs.
 
Medical protocols are sets of predetermined criteria that define appropriate nursing interventions and describe situations in which the nurse makes judgments relative to a course of action for effective management of common patient problems. Examples include:
  • Heparin administration
  • Insulin infusion
  • Wound care
  • Pain management
  • Dietary management
The CMS Interpretive Guideline §482.24(c)(3)—which is related to orders—does not include a standard definition for "standing orders." However, in the hospital community at large, the terms pre-printed standing orders, electronic standing order, order sets, and protocols are ways in which the term standing orders has been applied.
 
Continue reading "Patient care orders/protocols: What do the regulations say?" on the HCPro website. Subscribers to Medical Records Briefing have free access to this article in the April issue.

 

 



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