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Inherent in the practice of protocol medicine is the need for physician backup when the problem falls outside the scope of the protocol or the particular practice. A family physician may make a practice of referring all patients with cardiac arrhythmias to a cardiologist. This is not a legal requirement; it is just good sense. A nurse-practitioner who is working off protocols must refer patients who have problems beyond the scope of the protocols or the practice. The inclusion in the protocol of specific reasons for referring allows the physician to highlight conditions that are of particular concern. The protocol also may branch to other protocols if indicated.


Refer to the physician all patients with a rash, a heart murmur, or who appear toxic.

Consult the physician on all patients who cannot take penicillin or erythromycin.

Consult the physician on all patients under 6 months of age.

Refer to the emergency room by EMS all patients with respiratory distress or stridor. do not examine.

Refer to the "Otitis Media" protocol all cases that involve concurrent ear infection.

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