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Standards for giving client-specific orders

Part 2: Scope of practice standards

Standards for giving client-specific orders

1.

Nurses accept sole accountability and responsibility for the orders they give.

2.

Nurses give client-specific orders for activities that are:

  • within autonomous scope of practice,
  • within the nurse’s individual competence,
  • consistent with any relevant standards, limits and conditions established by CRNBC,
  • consistent with organizational policy, procedures and restrictions.

3.

Nurses only give client-specific orders when organizational supports, processes and resources, including policies and procedures, exist that:

  • outline the accountability and responsibility of the nurse,
  • ensure continuity of care for the client including the requirements and procedures for responding to questions about orders, amending orders and evaluating client outcomes.

4.

Nurses carry out assessments and make an appropriate nursing diagnosis1 to ensure that the client’s condition can be improved or resolved by the ordered activity before giving a client-specific order.

5.

Nurses give client-specific orders that consider the unique characteristics, needs and wishes of the client, contain enough information for the order to be carried out safely and are:

  • based on evidence
  • clear, and complete
  • documented, legible, dated and signed with a unique identifier such as a written signature or an electronically generated identifier

6.

Nurses give verbal or telephone orders only when there are no reasonable2 alternatives and it is in the best interest of the client. In these situations, nurses:

  • ensure that they have the necessary information  to conduct the assessment required to give the order, which may include gathering information from another health care provider when the nurse  is not able to directly observe the client
  • ask for the order to be read back to confirm it is accurate
  • follow up to ensure that the order is documented in the client record

7.

Nurses using documents that set out the usual care for a particular client group or client (e.g. pre-printed orders or order sets) make the information client-specific by adding the name of the individual client, making any necessary changes, dating their orders and signing with their unique identifier.

8.

Nurses identify the specific document (e.g. a decision support tool), in the client's record, including the name and the date of publication, when they reference that document in a client-specific order.

9.

Nurses follow the standards for Acting within Autonomous Scope of Practice and/or Giving Client-specific Orders when they change or cancel a client-specific order and are responsible and solely accountable for any changes that they make.

10.

Nurses communicate and collaborate with the professional who gave the order, the client and other members of the health care team when changing, or cancelling a client specific order.

11.

Nurses follow legal and ethical obligations regarding consent for the care referred to in their orders.

Applying the standards for giving a client-specific order

Footnotes

1 Certified practice registered nurses may also make a diagnosis of a disease, disorder or condition that is within the autonomous scope of the nurse’s certified practice designation and the nurse’s individual competence.
2 Reasonable refers to the common understanding that registrants of the nursing profession would have as to what is appropriate in the situation.
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