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The purpose of Standardized Procedures (more familiarly known as Standing Orders or SOP's) is to enable RN's to perform certain specified clinical procedures without first obtaining a provider order.
"Standardized procedures allow patient care to be shared among non-clinician members of the care team and empower RNs to function to their fullest capacity. Standardized procedures increase efficiency, improve patient satisfaction, and facilitate timely access to appropriate care. Based on a patient’s reported symptoms and objective assessment, the RN may follow implement these procedures. Doing so will expedite the triage process, accelerate provider evaluation, augment provider productivity, and increase appointment access.
Licensed Vocational Nurses (LVN’s) may also use these standardized procedures once they have gathered data from the patient and reported that data to a provider or RN. The provider or RN will then direct the LVN to use the appropriate standing order for the particular patient. "
RN Protocol for Administration of Depo-Provera CSM.151
This SOP describes the steps for initiating and continuing Depo-Provera injections.
For pregnancy-capable patients aged 12-52.5 years.
Clinician order is needed for initiation. This may be done via EMV at the first visit, clinician appointment for first injection, or a birth control consult appointment prior to scheduling the first injection.
Key Points
Must ensure "Birth Control Shot and Brain Tumors" education has been documented and consent obtained
Use appropriate EMV templates
Depo Provera Perpetual Calendar
Consent process
RN Protocol for Emergency Contraception CSM.150
This SOP allows RN’s to send in ECP without the patient having a clinician visit.
ECP is recommended when no contraception was used, there was incorrect use of a contraceptive or maybe it was it failed.
There are two commercially available oral emergency contraception choices: levonorgestrel most commonly known as Plan B or Ulipristal.
ECP is most commonly done via TE.
Providers who do not prescribe EC
UTI Standardized Procedures CSM.147
This SOP allows RN's to diagnose and treat uncomplicated UTI's in female patients aged 18-59 years based on clinical assessment and urinalysis.
Who: Patients with a positive TB test
What: Use the "LTBI pre-treatment evaluation" template to ask the screening questions and order the chest xray
Who: Patients with CGM's
What: Download and review report
Parameters:
Frequent hypoglycemia:
Greater than 2 episodes of hypoglycemia in 2 weeks (less than 70)
One episode of severe hypoglycemia (<54 or requiring assistance)
Time below range >10%
Ensure pt has a prescription for Baqsimi or Glucagon kit/Gvoke
Elevated glucose levels:
Glucose greater than 400 (High) with symptoms of hyperglycemia
Less than 35% Time in Range
Who: Diaper wearing pediatric patients presenting with a rash
What: Assess patient, including diaper area
Parameters:
Clinician involvement required if/when"
If the rash is not going away, or it is getting worse after two to three days of appropriate treatment.
If the rash includes pimples, peeling open skin, blisters, pus-filled, oozing, or crusty sores.
If the baby is taking antibiotic medicine and develops a bright pink or red rash with red spots at the edges.
If the rash is especially painful or warm, which could all be signs of cellulitis.
If the baby has a fever in addition to the rash.
Who: Patient with cardiac symptoms, who need pre-op clearance, or are on medications which prolong the QTC interval
What: Perform EKG
Parameters: EKG Must be reviewed by a clinician
Who: Patients over 3 months old with a temperature at or above 100.4
What: Administer weight-based acetaminophen and/or ibuprofen
Parameters:
Infants younger than 6 months: no ibuprofen
Patient has not had fever-reducing medication within the last 4 hours
Who: Patients with a blood gluose less than 70 with or without signs/symptoms of hypoglycemia
What: Administer oral glucose; recheck in 15 min. May repeat once more.
Parameters: If unconscious, with altered mental status, or unable to swallow: Administer glucagon IM, notify clinician, and call EMS.
For aged less than 48 hours, follow this protocol: Newborn hypoglycemia
Who:
Nebulizer: Patients with wheezing or diminished breath sounds with increased pulse, decreased pulse oximetry reading, nasal flaring, retractions, and/or other signs of respiratory distress.
O2 therapy: Signs and symptoms of shortness of breath/respiratory distress, such as labored breathing, respiratory rate above 20 or less than 12 (adults), O2 saturation less than 92%.
What:
Nebulizer: Ipratropium/albuterol (DuoNeb) (0.5mg/2.5mg/3mL)
•Infants and children: 1.5 – 3mL
•Adolescents and adults: 3mL
Repeat albuterol nebulizer as needed
O2 therapy: Administer oxygen to keep O2 saturation above 92%
Parameters: Notify provider that these orders were initiated and schedule an ASAP clinician visit or refer to ED.
Telephone triage Neighborhood uses Telephone Triage Protocols for Nurses, 6th edition, as a reference for clinic RNs triaging patients virtually. Call Center RN’s use the Clear Triage platform, which houses the Schmitt-Thompson telephone triage protocols.
RN’s and LVN’s are authorized to assess a patient’s immunization status using various resources and administer necessary vaccines. These resources may include:
1. Patient immunization records
2. State registry
3. Electronic Medical Record
4. Centers for Disease Control (CDC) vaccine schedule and recommendations
5. Titer results
6. For more information, see CSM.154 Immunizations/Vaccines
Urinalysis (UA): Patient with symptoms consistent with urinary tract infection (UTI), such as dysuria, lower abdominal pain, flank pain.
Urine HCG: Symptoms consistent with pregnancy, lower abdominal pain in persons of child-bearing age and ability, prior to Depo-Provera initiation.
Rapid Strep: Symptoms consistent with strep throat such as sore throat, enlarged tonsils, exudate on tonsils/throat.
Rapid Flu: Symptoms consistent with influenza such as headache, cough, body aches, fever.
Rapid COVID: Symptoms consistent with COVID such as headache, cough, body aches, fever. See also SO.001 Standing Order for COVID Testing
Rapid RSV: Symptoms consistent with RSV such as cough, congestion, fever.
Glucose: Symptoms of hypo- or hyperglycemia, such as dizziness, altered mental status, history of diabetes.
For results less than 49 or HHH, follow the steps in the Lab.008 Critical Result Policy .
See also Hypoglycemia protocol in section F of Standardized Procedures policy.
HgA1C: History of diabetes
PT/INR: Symptoms of bleeding, patients on anticoagulant treatment.
Hemoglobin (Hg): Patients with signs of symptomatic anemia, such as dizziness, pallor, bleeding, shortness of breath, fatigue.
For results less than 9 or greater than 19, follow the steps in the Lab.008 Critical Result Policy
Lab tests will be ordered in the electronic medical record (EMR) and collected, performed, and documented according to product instructions and policies. See reference links for more information.
Ordering provider. The patient’s primary care provider (PCP) or the provider who has an appointment with the patient that day should be used as the ordering.
H. Pylori re-test
•H. Pylori + patients at least 4 weeks after completing H. Pylori treatment
QuantiFERON
•Established patients and patients who are assigned to Neighborhood but have not yet established care.
•Positive TB Risk Assessment
•School/employment requirements
•QuantiFERON is preferred for patients over 2 years of age; the tuberculin skin test (TST) is also appropriate
Titers
•Established patients and patients who are assigned to Neighborhood but have not yet established care.
•The patient needs titers to determine if re-vaccination is needed (may be for school requirements, travel, work, etc.)
•MMR, Varicella, and/or Hepatitis B
Gonorrhea/Chlamydia test of cure
•Patients aged 18+ who completed treatment for gonorrhea and/or chlamydia
•Re-test for infection at least 3 months after completing treatment and no more than 1 year after completing treatment.
Bilirubin
•Newborns with elevated transcutaneous bilirubin (TcB).
Wound Care Standardized Procedure Policy CSM.163
General wound care principles
Assess wound and document. Take pictures if able to and upload into eCW. Uploading photos
Clean with normal saline or dermal cleanser, ensuring that dirt and foreign bodies are removed.
Apply topical antibiotic to wound bed when appropriate.
Cover with appropriate dressing for wound type.
Tetanus Prophylaxis PRN per immunization protocols
Consult with a provider if any of these are present:
Wound that requires suture
Wounds with signs/symptoms of infection
Fever, chills, or evidence of systemic infection
Wounds with functional disturbance
Facial wounds
Bleeding that can’t be easily controlled
Wound assessment and dressing selection
RN Protocol for Treatment of Chlamydia CSM.127
Who it applies to: Patients and their partners who are 12 years or older.
Provider responsibilities:
Order appropriate medications.
The patient may be scheduled for a Nurse visit or Enhanced Medical Visit for treatment and education.
Nurse responsibilities:
Review the patient’s test results and medical history.
If treatment wasn’t already provided, nurses ensure the correct medication is prescribed.
Nurses educate the patient on the infection, medication, notifying partners, and retesting after 3 months.
Medication treatment:
Standard treatment: Doxycycline for 7 days (unless allergic or pregnant).
Alternatives for allergies/pregnancy: Azithromycin or Amoxicillin.
Breastfeeding patients cannot take doxycycline; they must pause breastfeeding or choose another medication.
Patient education includes:
How to take the medication and why it’s important.
Advising patients to inform their sexual partners from the past 60 days to get tested and treated.
No sex until 7 days after completing treatment—if unavoidable, use a condom.
Partner treatment:
Partners must get a prescription (the clinic cannot directly give medication).
If the partner has allergies, they must come in for an appointment.
Provide education materials to partners about Chlamydia treatment
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