When a doctor writes standing orders telling a nurse to give certain medications under specified conditions, can the nurse legally carry them out? And does it make a difference whether the medications are controlled substances?
Apply this to your situation
This page answers the general question as of 1979. Ask about yours and see what current North Carolina law means for your facts, with citations you can check.
Plain-English summary
A state alcohol and drug abuse official asked whether a registered nurse could carry out a physician's standing order that named a condition and the medication to give when that condition arose. The Attorney General answered yes in 1979, but only if the Board of Medical Examiners had approved that nurse to perform medical acts under the joint medical and nursing board regulations.
The answer changed for controlled substances. The AG concluded that an RN could not carry out a physician's standing order involving a controlled substance, even with board approval. The opinion quotes 32E NCAC .0003, which allowed certain prescriptions on a supervising physician's specific orders "except controlled substances" and said no approved nurse could write or issue a prescription for a drug specified as a controlled substance under the Federal Controlled Substances Act.
The opinion does not discuss telephone orders, individual patient orders, other methods of administration, or a workaround for controlled-substance standing orders. Its conclusion concerns the standing orders described in the official's question.
Currency note
This opinion was issued in 1979 under the statutes and joint board rules it quotes. Check current North Carolina nursing and prescribing law before applying it to present practice.
What this means for you
Nurses and supervising physicians. Under the 1979 framework, approval by the Board of Medical Examiners mattered for carrying out the standing orders described in the request. The opinion says approval did not permit standing orders involving controlled substances.
Program administrators. The opinion distinguishes between a non-controlled medication covered by an approved nurse's standing orders and a controlled substance. It provides no alternative procedure for the latter.
Common questions
Could any registered nurse carry out the physician's standing orders?
No. The AG said only nurses approved by the Board of Medical Examiners under the joint regulations could carry out the standing orders at issue.
Did board approval allow standing orders for controlled substances?
No. The AG's second conclusion says an RN may not carry out such orders "even if that registered nurse has been approved" to perform medical acts.
Could a nurse use a specific telephone order instead?
The opinion does not answer that. The quoted regulation discusses some prescriptions on a supervising physician's specific orders, but expressly excludes controlled substances from that provision. The AG gives no substitute workflow.
Why did the opinion discuss prescriptions when the question was about giving medication?
The AG relied on the controlled-substance exclusion in the joint rules' prescribing provision to answer the standing-order question. Its stated holding is that the nurse may not carry out a standing order involving a controlled substance. It does not separately rule on every kind of medication administration.
Background and statutory framework
G.S. 90-18 defined practicing medicine broadly. Subsection (14) excepted registered nursing practice and medical acts performed by an RN under rules developed jointly by the Board of Medical Examiners and the Board of Nursing. The opinion says the joint rules were codified in Subchapter 32E of the North Carolina Administrative Code.
The rule quoted at 32E NCAC .0001 described an approved nurse working under a physician's direction or supervision, with standing orders included in the supervision arrangement. The rule quoted at 32 E NCAC .0003 addressed prescribing and expressly excluded controlled substances from prescriptions the nurse could write or issue. The AG read these rules together to reach its two answers.
Citations
- G.S. 90-18
- G.S. 90-18(14)
- 32E NCAC .0001
- 32 E NCAC .0003
- Federal Controlled Substances Act
Source
Original opinion text
Requested By: F. E. Epps, Coordinator of Regulatory Section, Office of Assistant Secretary for Alcohol and Drug Abuse
Questions:
May standing orders of a physician, which describe certain conditions and the medications to be given once it has been determined that those conditions exist, be carried out by a registered nurse?
May those standing orders be carried out by a registered nurse when the medications described are controlled substances?
Conclusions:
Standing orders of a physician, which describe certain conditions and the medications to be given once it has been determined that those conditions exist, may be carried out by a registered nurse if that registered nurse has been approved by the Board of Medical Examiners to perform medical acts.
A registered nurse may not carry out standing orders of a physician which involve controlled substances even if that registered nurse has been approved by the Board of Medical Examiners to perform medical acts.
The primary question for determination is whether or not standing orders of a physician, which describe certain conditions and the medications to be given once it has been determined that those conditions exist, may be carried out by a registered nurse.
G.S. 90-18 defines practicing medicine as "diagnosing or attempting to diagnose, treating or attempting to treat . . . or prescribing for or administering to, or professing to treat any human ailment, physical or mental or any physical injury to or deformity of any other person."
Any act which comes within this definition may be done only by a licensed physician unless the act is specifically authorized by another statute or regulation.
Certain acts are specifically authorized when they are performed by a registered nurse.
G.S. 90-18(14) specifically excepts from the definition of "practicing medicine": "The practice of nursing by a registered nurse engaged in the practice of nursing and the performance of acts otherwise constituting medical practice by a registered nurse when performed in accordance with rules and regulations developed by a joint subcommittee of the Board of Medical Examiners and the Board of Nursing and adopted by both boards."
These rules and regulations are codified as Subchapter 32E of the North Carolina Administrative Code, and are entitled "Approval of Registered Nurse Performing Medical Acts." These regulations define "registered nurse" as a "registered nurse who is functioning and performing medical tasks at the direction of or under the supervision of a physician licensed to practice medicine in North Carolina, and which nurse is approved by the board defined in the regulations as the Board of Medical Examiners of the State of North Carolina as being qualified by training and experience to perform the functions and tasks outlined in the application at the direction of or under the supervision of a physician."
Standing orders are specifically mentioned in the description of what is meant by the term "under the supervision of a physician." The regulations state that "The backup physician shall be available on a regularly scheduled bases for . . . review of the registered nurses' practice, between conferences incorporating chart review and co-signing records to document accountability: prescribing within that practice setting, standing orders and drug protocol for interval between conferences to be part of this regular review and documentation." (32E NCAC .0001)
Thus, standing orders of physicians as described herein may be carried out by registered nurses who have been approved by the Board of Medical Examiners under the terms of the regulations and it is the opinion of this Office that the intent of the regulations is that only registered nurses approved by the board may carry out standing orders of a physician.
A secondary question to be determined is whether or not standing orders of a physician which name controlled substance as the medication to be given once it has been determined that certain conditions exist may be carried out by a registered nurse. The regulations state:
"When the proposed medical functions of a registered nurse include prescribing of drugs, the supervising (backup) physician and the registered nurse shall review the formulary approved by the North Carolina Board of Nursing and the Board of Medical Examiners of the State of North Carolina, and shall acknowledge in the application to the board that they are familiar with the formulary, and that the formulary will be a part of the incorporated in the approved standing orders. Changes in the formulary are to be approved by the board. In regard to changes, the approved formulary may include any over-the-counter or non-prescription drug.
Prescriptions, except controlled substances, (Emphasis ours) may upon specific orders of the supervising physician, given before the prescription is issued, be written and issued by such registered nurse for the use by patients of drugs which are not included in the formulary. . . . However, no prescription shall be written or issued by such registered nurse for any drugs which are specified as controlled substances under the Federal Controlled Substances Act." (32 E NCAC .0003)
Thus, it is the opinion of this Office that a registered nurse may not carry out standing orders which involve controlled substances.
Rufus L. Edmisten
Attorney General
Ann Reed
Special Deputy Attorney General
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