Accreditation & Regulatory Journal
November 2023


CMS Essentials for Standing Orders

Provided By:
By: Connie Compton
Standing orders (sometimes referred to as staff-initiated orders, delegation protocols, standing procedures, etc.) empowers clinicians to launch orders based on defined and approved criteria. While standing orders are not perfect for every situation, there are many situations when standing orders can facilitate efficient patient care and improve staff satisfaction. Yes, that’s right – staff satisfaction! A recent study (Ford et al., 2023) found that ordering low-risk medications through standing orders increased staff satisfaction and decreased the clerical burden of paging and texting practitioners to obtain orders. Before quickly jumping in, it is important to assure your hospital’s standing orders are managed in a manner consistent with CMS regulations. Let’s look at the CMS essentials for standing orders.
Choose and clearly define your terminology - Whether you choose staff-initiated orders, delegation protocols, standing procedures, or standing orders, it is important to standardize a name for this type of order. To align with CMS, we are going with the term standing order. A standing order allows initiation of treatment by licensed staff (i.e., without a prior specific order from the treating practitioner) but not without clear, approved guidance. Treatment is initiated when a patient’s condition meets certain pre-defined criteria. For example, a standing order may be initiated as part of an emergency response or as part of an evidence-based treatment regimen where it is not practical for a nurse to obtain either a written, authenticated order or a verbal order from a licensed practitioner prior to providing care.
Hospital Policy
The hospital must have a written policy for standing orders outlining the process by which a standing order is developed; approved; monitored; initiated by authorized staff; and subsequently authenticated by physicians or other practitioners responsible for the care of the patient.
Evidence-Based & Specific Criteria
  • The hospital must be able to provide documented evidence that standing orders are consistent with nationally recognized and evidence-based guidelines.
  • For each approved standing order, there must be specific criteria clearly defined in the protocol for the nurse or other licensed clinician to initiate the standing order (e.g., the specific clinical situations, patient conditions, or diagnoses by which initiation of the order would be justified).
  • Protocols should be algorithmic in nature by providing clear instructions regarding medication administration. Commonly, scope of practice prohibits staff from self-determining the name, dose, route, frequency, device, etc. Under no circumstances may a hospital use standing orders to allow staff that are not authorized to write patient orders to make clinical decisions outside of their scope of practice and initiate standing orders.
Annual Review & Approval
Each standing order must undergo an annual review to determine the continuing usefulness and safety of the orders / protocols. A committee may prepare the review, as long as the medical staff, nursing leadership, and pharmacy leadership read, review, and approve the final standing order. The review process should include, but is not limited to the following questions:
  • Is the standing order aligned with the latest standards of practice reflected in nationally recognized, evidence-based guidelines?
  • Have preventable adverse patient events resulted from the use of the standing order? And if so, whether changes in the standing order would reduce the likelihood of future similar adverse events?
  • Has the standing order been initiated and executed in a manner consistent with the order’s protocol? An if not, whether the protocol needs revision and/or staff need more training in the correct procedures? Medical Record Documentation
  • An order must be initiated for each specific patient.
  • The order must be added to the patient’s medical record at the time of initiation, or as soon as possible thereafter.
  • A physician or other practitioner responsible for the care of the patient must acknowledge and authenticate the standing order (except for influenza and pneumococcal vaccines).
In summary, the process for standing orders requires evidence-based development, consistent implementation, and ongoing oversight with medical staff, nursing, and pharmacy approval. Lastly, the standing order must be authenticated and documented in the medical record.
1. Center for Medicare and Medicaid Services. (2020). State Operations Manual, Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals. Retrieved from
2. Ford, Claire C.; Clements, James B.; Luty, Jacob T.; Sharpe, Jackie K.; Caldera, Brittney N.; Hunter, Alan J. Implementation of a Nurse-Driven Medication Ordering Protocol to Improve Clinician and Nursing Experiences. Journal for Healthcare Quality 45(1) p 1-9, January/February 2023. DOI: 10.1097/JHQ.0000000000000369