PUBLIC HEALTH NURSING GUIDELINES AND ORDERS

 

The Oklahoma Nursing Practice Act 59 O.S.567.3 states, "The practice of nursing means the performance of services provided for purposes of nursing diagnosis and treatment of human responses to actual or potential health problems consistent with educational preparation. .... This practice includes execution of the medical regime including the administration of medications and treatments prepared by any person authorized by state law to so prescribe."  The Oklahoma Board of Nursing has no interpretative statement regarding this portion of the Act but the Board recommends that an institution have written guidelines that do not exceed the Nurse Practice Act for the use of approved orders.

"Approved orders" is a commonly used phrase in most institutions providing nursing services.  An approved order is a medical function, task, or act that has been delegated to another individual, most commonly a nurse, by a licensed physician in accordance with the Medical Practice Act.  Because of the accepted usage of the legal basis of approved orders, it is both necessary and proper that public health nurses should have approved orders to authorize them to administer a treatment or medication when a physician is not present.  Within this agency the approved orders, which represent medically delegated functions, are to be used in conjunction with the public health nurse guidelines.  In addition to these public health nursing guidelines and orders, the agency acknowledges that there are other existing standards and guidelines that may have applicability as well.

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The criteria listed below should be followed in the utilization of these guidelines and orders.

1.  All public health nursing guidelines and orders should be reviewed annually.  The orders should be signed annually by the county health department medical director and   remain in effect until superceded by a new set.

2.  Specific orders received by telephone or verbally must be countersigned by the physician, physician’s assistant and advance practice nurse (with prescriptive authority) within 7 days after the order is received.  This task can be accomplished using ODH Form  # 303M.

3.  The District Nurse Manager or designee is responsible for having valid current orders for all public health nursing and nurse practitioner services provided in the health department.

4.  Each nurse is individually responsible for his/her actions and should be knowledgeable of all guidelines and orders.  Any nurse acting beyond the approved orders would be practicing beyond the scope of his/her employment.

5.  Once signed by the physician or person with prescriptive authority, an order that is altered would be considered invalid. 

6.  An original file should be used to maintain the original copies of the order signature pages that have been signed by the medical director for each county.  This file should also contain the original copy of the signature page for the advance practice nurse guidelines and orders for that particular county.  If the physician makes major changes in a particular order, the actual page of the order must be signed and dated by the physician and a copy of the amended order should be sent to Nursing Service within seven days of signature.  The original of this page should also be maintained in this file.

7.  The Physician’s Signature Page should be used to obtain the medical director’s signature, thus validating the orders.  Photocopies of this page should be placed with the site’s working set of guidelines and orders.  The original signature page should be placed in the original file kept at the county health department.

8.  Only one original set of signature pages for the orders per county that have been signed by the medical director should exist.  The advance practice nurse should have only one original set of his/her orders signed by each back-up physician. It is imperative that only one set of original orders exists for archival storage.

9.  All original physician signature pages and the original set of guidelines and orders must remain in the county until a new signature page is signed for new orders.  Within 30 days of being superceded, all original signature pages and the page(s) of any order that has been changed by the medical director/physician must be assembled for each county and forwarded to Nursing Service for archival storage.  For further information regarding this process contact Nursing Services.

10.  If the ARNP without prescriptive authority writes an order for a medication that the PHN does not have a guideline/order covering the issuance of that medication then the ARNP should issue the medication to the client. For example: an order for Flagyl; the treatment of anemia in a family planning client; and the treatment of a symptomatic UTI in family planning. A PHN does not have an order to cover issuance of Flagyl, iron in adults or for the treatment of UTI in family planning, thus the ARNP without prescriptive authority must issue the medication.