St. Mark's Hospital - November 01, 2016

Starting immediately, medication orders that state a range of doses that may be selected by the person administering the medication must include specific patient assessment criteria for each dose. Most standard order sets have been designed in Epic with this Joint Commission requirement in mind. However, medication orders entered by free text or created by you as a custom order set could be created without including the necessary criteria. If such range orders without criteria are identified, you will be contacted by the pharmacy for clarification.

Titration orders for drips are fine, as long as parameters for titration are included. Sliding scales for insulin are also fine, as long as the criteria stated designate a specific dose. This avoids placing the nurse in the untenable position of making medical judgments outside their scope of practice and supports safe medication administration practices.


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