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The term protocol is widely used in health care to refer to a variety of documents. We use protocol to refer to written guidelines directing the practice of nurses and other PEs. These protocols are not intended to be clinical algorithms; unlike clinical algorithms, which are intended to assist medical decision making, protocols are intended to circumscribe clinical decision making.[87]

Few medical offices use the detailed, deterministic protocols described in this chapter. Such protocols require substantial effort to compile and tailor to the needs of an individual physician's office. In the long term, however, they become time-effective by rationalizing quality assurance efforts and the analysis of work flow in the office. More important, systematically using structured protocols reduces the burden of routine documentation of patient encounters. If an office relies on standard protocols to determine the diagnosis and treatment of common conditions, these protocols become generic documentation for those conditions. As long as the physician can convince a court that the protocols are enforced, the protocol becomes evidence of a pattern of behavior. In this case, the burden of proof is shifted to the plaintiff, who seeks to dispute that the protocol was not followed. If the office does not rigorously enforce the use of protocols, each patient encounter must be fully documented. In effect, the core of what would be the protocol must be written as a chart entry every time the condition is treated. Failing in this repetitive documentation shifts the burden of proving what care was rendered to the physician.

[87]Hadorn DC; McCormick K; Diokno A: An annotated algorithm approach to clinical guideline development. JAMA 1992 Jun 24; 267:3311-3314.

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