Forms of a Valid Order

An order is a direction from a regulated healthcare professional with legislative ordering authority (e.g., physicians, registered nurses in the extended class, dentists, midwives) that permits the performance of a procedure by another healthcare professional (regulated and non-regulated).

There are two forms of a valid order:

1. Direct Orders

A direct order is one that is authorized by an individual prescriber at the time care is to be delivered for a specific patient/client for a specific treatment or intervention. The date and time that the intervention should occur may also be specified in a direct order. A direct order may be written in the patient/client’s medical records*, or may be in the form of prescriptions or requisitions, and should include the following information:

when the order is given (i.e., date, time);

who the order is for (i.e., patient/client identification);

who the prescriber is – accompanied by the prescriber’s signature; and,

details of the intervention (e.g., treatment/procedure to be undertaken, when the order is to be carried out, dose/frequency/mode of administration, etc.)

* direct orders may be given in writing, electronically and verbally. Please review the sections in this document entitled Verbal Orders and Electronic Orders.

Example…

Patient: Mr. Brown

Jan.1/19 (1000) – RT to administer 4 puffs of Salbutamol (100 mcg/puff) QID.

Signed: Dr. One

PLEASE NOTE:

An RT-driven protocol is a type of direct order. These protocols outline a pre-designed plan of care to be delivered to a specific patient; often with the use of an algorithm to guide the RT’s decision-making processes (e.g., Ventilation-Weaning Protocol).

An Order Set (either in a paper-based or digital format) can be used to implement a direct order, provided it contains all the necessary information (e.g., patient identifiers, name of authorizer, etc.).

2. Medical Directives

A medical directive is an order that is authorized in advance by either an individual prescriber or a group of prescribers for a specified range of patients for who meet specific conditions.

A properly constructed medical directive must include the following:

the name and description of the procedure, treatment or intervention being ordered;

the recipient patients/clients;

the authorized implementer(s) who are permitted to release the medical directive and either:

perform the intervention themselves; or

request that a co-implementer perform the intervention.

indications and contraindications* (e.g., Indications – Signs and symptoms of respiratory distress associated with bronchospasm)

* may attach an appendix that provides a detailed outline.

any educational requirements required (e.g., only Respiratory Therapists who work in a certain area and have advanced certification or have completed continuing education, etc.);

the physician(s) or other health care professional authorizing the medical directive;

a list of administrative approvals from the facility with dates and signatures; and

all relevant appendices attached to the medical directive.

Example…

All RNs on a paediatric unit may be listed as the implementer of a medical directive for bronchodilator administration, and all the RTs in the hospital may be listed as the co-implementers. When the RN feels that a patient/ client meets the criteria outlined in the medical directive, they may contact the RT and ask that the medical directive be implemented. The RT would then perform their own assessment and if they agreed that the patient/ client meets the criteria, they can administer the bronchodilator.

PLEASE NOTE:

To be a valid order, a medical directive must be signed by at least one authorized prescriber (e.g., physician). However, employers often have policies regarding who must sign a medical directive. For example, an employer can stipulate that the Chief of Emergency Medicine must sign all ER directives on behalf of the entire department, or they may require signatures from all physicians whose patients will be impacted by the directive.