Skip to:

Use of Condition-Specific Protocols

Frequently Asked Questions

Use of Condition-Specific Protocols FAQ

  • Implementation of a protocol that results in a prescription: What should a nurse consider?

    Pharmacy and nursing laws permit an authorized prescriber to "predetermine" a prescription under certain circumstances.

    registered nurse may implement a protocol that does not reference a specific patient and results in a prescription of a legend drug that has been predetermined and delegated by a licensed practitioner as defined under section 151.01, subd. 23 ( when the patient condition falls within the protocol and the protocol specifies the circumstances under which the drug is to be prescribed or administered.

    Licensed practical nurses and registered nurses may implement a protocol that does not reference a specific patient and results in the administration of a vaccine that has been predetermined and delegated by a licensed practitioner when the patient characteristics fall within the protocol and the protocol specifies the contraindications for implementation, including conditions under which the vaccine must not be administered.

    Many times a condition specific protocol that results in a prescription of a legend drug is accompanied by a telehealth care guideline that may include clinical decision making tools. If the patient's condition falls within a category of treatment that includes the issuance of a prescription authorized by the prescriber's predetermined protocol, then the protocol can be implemented.



  • The Drug Enforcement Agency and the Board of Pharmacy have advised that Controlled Substances cannot be prescribed by use of a condition specific protocol due to state and Federal pharmacy and controlled substance laws.

    The registered nurse is responsible and accountable to give the same consideration when implementing a condition specific protocol as the nurse would make when determining whether to accept any delegated medical function. The following information developed in conjunction with the Boards of Pharmacy and Medical Practice may be helpful as a registered nurse considers accepting the delegation of medication administration either by patient specific order or by implementing condition specific protocols which result in the generation of a predetermined prescription.

  • Factors to consider when a registered nurse implements a condition specific protocol:
    1. Is the protocol specific to a condition?

    2. Has the condition been clearly defined by the signs and symptoms?

    3. Does the nurse have the requisite skill and knowledge to carry out the delegation safely and competently, that is, the knowledge, skills and abilities with regard to the patient condition?

    4. Does the protocol have clear and specific parameters to ensure the nurse is practicing within the scope of the practice of nursing and the nurse's level of education preparation?

    5. Does the protocol contain all components required of a prescription as defined by pharmacy law? (Minn. Stat. 151.01., subd. 16 and 23)

    6. Are the expected outcomes clearly communicated between the prescriber and registered nurse? 

    7. What feedback and evaluation will the nurse provide to the prescriber regarding implementation of the protocol?

    8. How will the nurse document the implementation of the protocol?

    9. What alternative steps will the nurse take if the protocol is not applicable or the nurse has concerns regarding the patient's care? Is an authorized prescriber available for consultation?

  • A protocol should identify:
    1. the population for whom the predetermined prescription may be implemented,

    2. the name and signature of the prescriber who initiated the protocol and predetermined prescription and the date it was written,

    3. the name, dosage, quantity, route of administration and directions for use of the drug or therapeutic device prescribed,

    4. the contradictions for implementation of the protocol and prescription,

    5. the specific time periods during which the predetermined prescriptions may be implemented, and 

    6. the circumstances under which a prescription may be filled or refilled.

    If the nurse uses a prescription form to transmit the order to the pharmacy, the Board suggests the nurse indicate the name of the authorized prescriber who signed the protocol, the name of the nurse who is implementing the protocol, indicate the prescription is generated per protocol, and identify the protocol in some manner.