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Sample Medical Directive

7. Sample Medical Directive

Title: Bronchodilator Administration

Number: 123-456

Activation Date: Jan. 1, 2024

Review due by: 2021

Sponsoring/Contact Person(s):
(name, position, contact particulars)

Director of Cardiorespiratory Services
Chief of Paediatrics
Chief of Emergency Medicine
Chief of General Internal Medicine
Order:

Appendix Attached: No
Title:

Administration of Salbutamol Sulfate via meter dose inhaler (MDI) and aerochamber or small volume nebulizer (SVN).
Recipient Patients:

Appendix Attached: No
Title:

Any inpatient. Also, any patient receiving services in the Emergency Department or in an outpatient clinic.
Adult: 18 years of age and older
Paediatric: 1 to 18 years of age
Neonate/Infant: birth to 1 year of age
Authorized Implementers:

Appendix Attached: No
Title:

All RRTs in this organization. RT(E)s, and GRTs may also implement this directive provided they do so under the general supervision of another regulated healthcare professional.
Indications:

Appendix Attached: Yes
Title: Indications

Signs and symptoms of respiratory distress with bronchospasm.

Contraindications:
Known allergy to Salbutamol Sulfate.
Patient/Substitute Decision Maker (SDM) does not consent

Consent:
Appendix Attached: Yes
Title: Consent Policy

All RRTs, RT(E)s and GRTs implementing this medical directive will first obtain informed consent from the patient/SDM in accordance with this organization’s Consent Policy, the CRTO’s Standards of Practice and the Health Care Consent Act.

Guidelines for Implementing the Order:
Appendix Attached: Yes
Title: Dosage Chart

The RRT/RT(E)s/GRT will:

  1. Perform respiratory assessment pre-treatment and determine if bronchodilator administration is necessary.
  2. Administer the bronchodilator in accordance with the attached dosage chart.
  3. Assess the patient’s response to treatment.
  4. Document in patient medical record and inform Most Responsible Physician (MRP) if the patient requires any further intervention(s).
Documentation and Communication:

Appendix Attached: No
Title:

Documentation should include:

  1. Date and time of administration.
  2. Dosage of bronchodilator given.
  3. Results of pre and post respiratory assessment.
  4. Name and number of the medical directive (e.g., “As per Bronchodilator Administration Medical Directive # 123-456”).
Review & Quality Monitoring Guidelines:

Appendix Attached: No
Title:

MRPs, RRTs/RT(E)s/GRTs, and RNs will monitor patients for any unintended outcomes arising from the implementation of this medical directive.

Administrative Approval (as applicable):

Appendix Attached: Yes
Title: MAC approval letter
Medical Advisory Committee (approved December 12, 2018)
Approving Physician(s)/Authorizer(s):

Appendix Attached: No
Title: 

Dr. One – Chief of Paediatrics

Dr. Two – Chief of Emergency Medicine

Dr. Three – Chief of General Internal Medicine

PLEASE NOTE:

The Health Profession Regulators of Ontario has developed templates for both medical directives and medical directive/delegation combined.