The most common way of delegating authority is to write an order in a hospital chart or otherwise formally record orders for NPPs. The physician may write the order in person, or a nurse may enter it in the chart at the physician’s direction. Formal orders are valuable for clarifying the delegation of authority in the hospital setting, though they are less commonly used in private offices.

Standing orders, which include protocols, are a special case of written physician’s orders. A standing order is an order conditioned upon the occurrence of certain clinical events. The important characteristic of a standing order is that all the patients who meet the criteria for the order receive the same treatment. A common use of standing orders is in public health clinics that treat specific diseases. A venereal disease control program will use the CDC protocols for antibiotic dosages. Once the specific venereal disease is identified, the nurse administers the antibiotics as specified by the CDC protocol and authorized by the physician directing the clinic. In this situation, the CDC protocol is a standing order from the medical director, and the conditional event is the diagnosis of a specific venereal disease.

It is important to differentiate standing orders from preprinted orders: orders that the physician uses repeatedly and has photocopied to save the trouble and potential errors of rewriting each time they are used. Although the orders are the same for all patients, they are not standing orders because they are not conditional. The physician, not the nurse, determines whether the printed orders will be used in a given case. Unlike a standing order, until the physician incorporates the printed order into the chart, the nurse cannot initiate treatment. Preprinted orders are a useful tool, but they can lead to problems if a patient requires a variation in the usual printed order. These variations must be carefully marked on the orders and the nursing staff notified that the printed order has been modified.

Direct orders are voice orders that are given directly to NPPs. Sometimes these orders are documented in the medical records, but usually they are carried out at once and not recorded. For example, when a surgeon directs the operating room nurse assisting in a procedure, some of the surgeon’s orders will be documented, but most will not. Documenting the individual orders is not a problem in this situation because the physician is directly supervising the nurse’s work. The satisfactory completion of the nurse’s work will be documented as part of the operative report.

In office practice, neither the voice orders nor their satisfactory completion will necessarily be documented in the patient’s chart. This makes it difficult to determine whether the physician has given a direct order, or the NPPs are acting out of routine. Unless these routine actions are carried out according to a strict protocol, the physician will not be able to ensure that the proper nursing functions have been carried out. If the physician is sued over a question about the nurse’s actions, there will be no record to establish what was done to the patient.