Title: Accepting, Verifying, Transcribing and Implementing Prescriber Orders

Advisory Ruling Number: 9324 (formally Verification of Orders)

Authority:
The Massachusetts Board of Registration in Nursing (Board) is created and authorized by Massachusetts General Laws (M.G.L.) c. 13, ss. 13, 14, 14A, 15 and 15D, and M.G.L. c. 112, ss. 74 through 81C to protect the health, safety, and welfare of the citizens of the Commonwealth through the regulation of nursing practice and education.  In addition, M.G.L. c.30A, s. 8 authorizes the Board to make advisory rulings with respect to the applicability to any person, property or state of facts of any statute or regulation enforced or administered by the Board.  Each nurse is required to practice in accordance with accepted standards of practice and is responsible and accountable for his or her nursing judgments, actions, and competency.  The Board’s regulation at 244 CMR 9.03(6) requires all nurses to comply with any other law and regulation related to licensure and practice.

Date Issued: September 22, 1993

Date Revised: July 10, 2002; December 9, 2009, October 8, 2014

Scope of Practice: Registered Nurse and Licensed Practical Nurse

Purpose:
To guide the practice of Registered Nurses and Licensed Practical Nurses when accepting, verifying, transcribing, and implementing patient care orders from a duly authorized prescriber (i.e., Advanced Practice Registered Nurses with prescriptive authority, Physician Assistants, and Physicians). 

Advisory:
It is the responsibility of the licensed nurse to ensure that there is a proper patient care order from a duly authorized prescriber prior to the administration of any prescription or non-prescription medication or activity that requires such order in accordance with accepted standards of practice and in compliance with the Board’s regulations.  Prescriber orders for non-pharmacologic interventions may be required by Federal or State law and/or regulation or by institutional policy and would be subject to this AR.

Nurse’s Responsibility and Accountability
Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations.  Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.  The paramount importance of patient safety must be reflected in practices that are specific to the setting and circumstance.  Determination of individual client/resident/patient allergy must be included in each situation. 

The nurse is accountable for ensuring that any orders he or she implements are reasonable based on the nurse’s knowledge of that particular patient’s care needs at that time and must also ensure that the orders (whether written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) originate from an authorized prescriber, pursuant to established protocols of the organization.  It is the responsibility and the obligation of a nurse to question a patient care order that is deemed inappropriate by a nurse according to his/her educational preparation and clinical experience.  In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber.  It is not within the scope of Licensed Practical or Registered Nurse practice to alter or change the directions provided for in orders from a duly authorized prescriber.  Licensed nurses are not authorized to prescribe, renew/refill, or extend a prescription that has expired prior to receipt of an order from duly authorized prescriber. 

While the determination to allow unlicensed persons to transcribe orders is pursuant to organizational policy and procedure, the implementing nurse is responsible for assuring the order is appropriate, accurate, and complete.

For the purpose of this Advisory Ruling the following apply:

Verbal/Telephone Orders:
Verbal/telephone orders include all patient care orders that are communicated as oral, spoken communications between prescribers and receivers face to face, by telephone, or by other auditory device, require transcription by the person receiving the order, and require a duly authorized prescriber signature to validate the order at a subsequent, defined time, not to exceed Federal or State requirements.

Standing Order / Protocol:
Standing orders/protocols include written authorization from a duly authorized prescriber that indicates evidence based practice standards for a specific medication or activity to be implemented by the nurse.  Standing orders/protocols are applicable to a specific patient or specific situation and directions remain consistent during implementation. 

Important considerations that must be included in all standing orders / protocols[1]:

    • The name(s) of the substance or activity to be administered;
    • If the order includes substance administration, the route or method and dose to be administered;
    • Inclusion/exclusion criteria that the nurse will assess for before administering the substance or activity;
    • The signature or approval of a duly authorized prescriber either directly on the standing order/protocol or on file with the facility/agency/program employing the nurse;
    • Specification of the details of patient presentation (subjective signs and symptoms);
    • As appropriate to the situation and setting, delineation under what circumstances the substance and/or activity is to be administered including;
      • specific medication dosing instructions based upon specific diagnostic biophysical marker parameters (e.g.,  laboratory testing, blood pressure reading, reported chest pain, signs and symptoms of overdose); and
      • specifics for subsequent diagnostic biophysical marker follow-up to assess response to intervention.
    • Specification of the circumstances under which the licensed nurse must seek emergent assistance for continued care (i.e., contact 911);
    • Provision of a manner of record keeping of accurate and detailed information regarding the encounter;
    • Provision of a mechanism for regular review, approval and monitoring by medical, pharmacy and nursing staff on defined occasions to determine continued currency, usefulness and safety of the standing order/protocol; and
    • Provision of a mechanism to ensure authentication by a duly authorized prescriber at a defined time frame, not to exceed Federal or State requirements.

Standing orders / protocols cannot authorize the nurse to:

    • alter the standing order / protocol once initiated (e.g., independently initiate new medications);
    • determine choice of intervention based upon a menu of medications or actions; and/or
    • prescribe, renew/refill, or extend a prescription that has expired.

Pre-printed Order Sheets
Pre-printed order sheets include tools generally designed to assist prescribers as they write orders.  Pre-printed order sets may include computerized programs that are the functional equivalent of hard copy preprinted order sets.  Such tools may include a menu of medications or actions from which the prescriber makes selections applicable to a specific patient or situation.  Pre-printed order sheets must be authenticated by a duly authorized prescriber prior to implementation by a licensed nurse.  Pre-printed order sheets designate evidence based practices in prevention, diagnosis, or management of symptom, disease or condition and are reviewed, approved and monitored by medical, pharmacy and nursing staff on defined occasions to determine continued usefulness and safety. 

Electronic Orders
Electronic orders include written orders received through electronic communications including, but not limited to, computerized prescriber order entry (CPOE), smart phone technology, email and fax.  Specific procedures that include guidelines for accepting, transcribing, authenticating and memorializing all orders received electronically must be readily available.

All Medication Orders

Minimum required elements:
The minimum elements required for inclusion in a complete medication order include[2]:

      • Patient/client/resident/student’s full name;
      • Name of the medication;
      • Dose and route of the medication;
      • Frequency of the medication administration;
      • A valid medication order date;
      • Specific directions for administration;
      • Signature of the duly authorized prescriber; and
      • Signature of the individual accepting/verifying the order

Pharmacy labeled container
In certain and limited situations, it is within the licensed nurse’s discretion to accept an original pharmacy labeled container in lieu of an order from a duly authorized prescriber. Situations include, but are not limited to:

      • Schools;
      • Adult & Pediatric day care;
      • Summer camp; and
      • Other nursing care settings

When choosing to accept an original pharmacy labeled container in lieu of an order from a duly authorized prescriber, the licensed nurse must consider the following:

      • The setting must have a policy and/or procedure guiding/directing this activity;
      • The medication container must be intact with a completely written and legible label;
      • The medication expiration date cannot be exceeded;
      • When indicated, there must be parental or guardian consent;
      • The label must contain all the perquisite information necessary prior to administrating a medication (e.g., The 5 Rights);
      • Determination of individual client/resident/patient allergy must be done; and
      • The nurse is accountable for ensuring that any orders he or she implements are reasonable based on the nurse’s knowledge of the patient’s care needs and that the orders originate from an authorized prescriber.

Role of the Nurse in a Management Role

The licensed nurse in a management role must develop and implement the necessary measures to promote the delivery of safe nursing care in accordance with accepted standards of care, such as those issued from time to time by The Joint Commission and The Institute for Safe Medication Practices.

Such measures must include and define at a minimum:

    • acceptable methods of order communication within the practice setting, including methods by which nurses ascertain that orders originate from an authorized prescriber;
    • circumstances in which defined methods can be used;
    • determining competency in accepting orders required for each method; and
    • specific safety measures that must be included to ensure patient safety:
      • telephone and other verbal orders must include read-back policies;
      • timeframes for authentication cannot exceed state or federal requirements;
      • abbreviation policies; and
      • any limitation on orders for specific substances that may be considered unsafe to prescribe in non-written format. 

References



[1] Based upon previous Board finding 1/11/12
[2] Based upon previous Board finding 12/09/09

This information is provided by the Division of Health Professions Licensure within the Department of Public Health.