RN Playbook

Expected Core Values Checklist
Validation Checklist for Core Nurse Clinics SP, Protocols, Policies

RN
RN, LVN, MA
Process Validation Tools
Skills Validation Tools

APPENDIX

Appendix

Definition of Terminology

Guidelines Non-mandatory recommendations for evaluation and care of patients developed after
review of the scientific literature to guide practice decisions (evidence-based clinical practice
guidelines). Guidelines are most appropriate to guide physicians and advanced practitioners
who can make independent clinical judgments about treatment decisions.
Example: Stroke Clinical Practice Guideline which includes recommendations for the
history and physical, EKG, lab tests, imaging, consultation, acute treatment, hospital
admission, post-acute care and rehabilitation.

Policy and The formal, approved description of how a governance, management, or clinical care
Procedure process is defined, organized, and carried out.
Example: Ear Irrigation in Family Practice for RNs and LVNs

Pre-printed An order sheet which was developed for use by the physicians to facilitate the ease of
Orders writing orders for a specific patient usually in the hospital setting. A pre-printed order is
patient specific and signed by the patient’s physician.
Example: ICU Standard Admission Orderset

Protocol A document that directs a practitioner’s actions in performing a specific procedure or
evaluating and treating a specific condition, including subjective and objective assessment,
the treatment plan or actions to take in response to those assessments, education, follow-up,
and circumstances when physician consultation or referral is required. For RNs, a protocol
is part of a Standardized Procedure and provides specific guidance as to performing a
particular procedure or function that overlaps with the practice of medicine. For Advanced
Practice Nurses, the protocol guides the formulation of treatment plans for specific
conditions. For Physician Assistants, the protocol also serves as a means of supervision of
the PA, combined with physician countersignature of at least 5% of the PA’s charts.

Standardized A specific written authorization for an RN to perform functions in an organized health care
Procedure setting that overlap with the practice of medicine and exceed the usual scope of practice of
the RN. The Standardized Procedure contains a protocol describing the actions that the RN
will take and under what circumstances. (See eleven requirements in BRN Standardized
Procedure Guidelines). SPs only apply to RNPs, CNMs, CRNAs and RNs. A Standardized
Procedure cannot allow an RN to diagnose or prescribe medication. Advanced practice
nurses with furnishing authority may furnish medication under Standardized Procedure.
Example: Intrauterine Insemination Standardized Procedure for NPs in Ob-Gyn Dept.

Standing A non-patient specific order developed by a physician to be followed for a category of
Orders patients. Standing orders are not used as medication orders because they are not patient
specific.
Example: All obstetrical patients get a urine dipstick test for protein and sugar at every
prenatal visits.

References Contacts:
For questions or inquiries regarding the content or recommendations contained in this document, please
contact the appropriate parties below:

Workgroup Member Titles/Contact Information
Sylvia Everroad, RN MSN
Project sponsor/ Chief Administrative Officer, SCPMG
Aileen Oh, RN MSN 626-405-7166 (Tie Line: 335)
[email protected]
Hazel Torres, RN MS
Director of Ambulatory Care Services, SCPMG
Lucy Hong, RN MSN 626-405-6944 (Tie Line: 335)
[email protected]

Assistant Director of Professional Development and Research, SCPMG
626-405-5051 (Tie Line: 335)
[email protected]

Administrative Fellow
[email protected]

References:
Ambulatory Practice Resources (http://ambulatorypractice.org)
KP Clinical Library References (http://cl.kp.org/portal/site/SCAL)
SCPMG Clinical Library - Clinical Practice Guidelines (http://cl.kp.org/pkc/scal/cpg/cpg/)
Southern California Drug Formulary (http://pharmacy.kp.org/KP-
CMS/National%20Portal/Dashboard/DashboardHome.aspx/)
California Board of Registered Nursing (http://www.rn.ca.gov/)
(http://www.rn.ca.gov/pdfs/regulations/npr-b-32.pdf)
California Law (http://www.leginfo.ca.gov)
California Code of Regulations (http://ccr.oal.ca.gov/linkedslice/default.asp?SP=CCR-
1000&Action=Welcome)
Code of Federal Regulations (http://www.gpoaccess.gov/cfr/index.html)
The Joint Commission (http://www.jointcommission.org./
Centers for Medicare and Medicaid Services (CMS) (http://www.CMS.hhs.gov/default.asp?)