Care Directives Pre-Printed Orders

The purpose of this document is to outline the practice expectations for nurses implementing care (medical) directives or preprinted orders¹ to carry out specific competencies that are within the scope of the nurse, but would otherwise require a client-specific, direct order from an authorized prescriber. The name of this document has changed to care directive to reflect current literature and reflect that nurses work within collaborative, interprofessional teams (e.g., with nurse practitioners (NPs), physicians, pharmacists, dentists, midwives, allied health etc.).

The College supports the use of care directives and preprinted orders in situations where evidence-based care protocols have been developed and adopted within an organization. Under the authority (written direction) of care directives and PREPRINTED orders, nurses may implement specifically identified health care interventions that are within the scope of practice of the nurse, but would otherwise require a client-specific, authorized prescriber order. The authority to perform a competency does not automatically mean it can be implemented. Nurse knowledge, assessment, competency, and judgment are always required.

Care directives and preprinted orders are two separate authorizing mechanisms, similar in purpose, that grant authority to nurses in specifically identified settings to implement specific interventions for a client or groups of clients with specific conditions or needs.

Care Directive: a written order from an authorized prescriber (e.g., physician, nurse practitioner, pharmacist, dentist, midwife, etc.) for a competency² or a series of interventions that may be implemented for a number of clients when specific conditions are met and when specific circumstances exist. The specifics of the care directive will depend on the client population, the nature of the orders involved, and the expertise of the health care professionals implementing the directive. It is only initiated if the health condition occurs.

• Is a written order/employer policy developed in consultation with an authorized prescriber(s) for a competency or series of interventions to be implemented by another care provider for a range of clients with identified health conditions/ needs when specific circumstances are met/exist.
• Apply to a range of clients who meet identified criteria (e.g., age or diagnosis). Does not require additional client specific authorization.
• Requires the nurse’s professional assessment, judgment, and evaluation.
• Allows for discretionary use. Based upon the nurse’s assessment and professional judgment, the nurse has the flexibility to determine if, and when, to implement a care directive, and when follow-up is required if the directive is not implemented (e.g., notify the authorized prescriber).
• Is an optional component of the client’s record. A copy may or may not be placed upon the client’s record; however, a copy of the directive must be readily available (e.g., available via policy manual). Having a copy of the care directive on the client’s record may be the recommended practice if the situation warrants, e.g., medications are to be administered or procedures are to be carried out over time by different health care professionals.
• Are based on evidence-informed best practices.
• Examples of client care that could be considered for a care directive include immunization schedule in public health/community care, and/or triage-related interventions in emergency departments.

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