Section 250.330  Orders for Medications and Treatments

a)         No medication, treatment, or diagnostic test shall be administered to a patient except on the written order of a member of the medical staff, a house staff member under the supervision of a member of the medical staff, or allied health personnel with clinical privileges recommended by the hospital medical staff and granted by the hospital governing board, with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per medical staff-approved hospital policy that includes an assessment for contraindications, and medications and treatments provided to patients in a hospital outpatient setting as set forth in a policy approved by the hospital medical staff and governing board.

1)         The staff-approved influenza and pneumococcal immunization policy shall include, but not be limited to, the following:

A)        Procedures for identifying patients age 50 or older for influenza immunization and 65 or older for pneumococcal immunization and, at the discretion of the hospital, other patients at risk;

B)        Procedures for offering immunization against influenza virus when available between September 1 and April 1, and against pneumococcal disease upon admission or discharge, to patients in accordance with the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention that are most recent to the time of vaccination, unless contraindicated; and

C)        Procedures for ensuring that patients offered immunization, or their guardians, receive information regarding the risks and benefits of vaccination.

2)         The hospital shall provide a copy of its influenza and pneumococcal immunization policy to the Department upon request. (Section 6.26 of the Act)

3)         The outpatient medication and treatment administration policy shall include, but not be limited to, the following:

A)        Procedures for verifying the credentials and scope of practice of non-medical staff members providing written orders for medications and treatment for patients under their care and management.

B)        Identifying what, if any, medications or treatments should not be included in this exception.

C)        A process for tracking non-medical staff members providing written orders for medication and treatments and the medications and/or treatments ordered.

4)         The hospital shall provide a copy of its outpatient medication and treatment policy to the Department upon request.

b)         Verbal orders shall be signed before the member of the medical staff, the house staff member, or allied health personnel with clinical privileges recommended by the hospital medical staff and granted by the hospital governing board leaves the area.  Telephone orders shall be used sparingly and countersigned by the ordering practitioner or another practitioner who is responsible for the care of the patient as soon as practicable pursuant to a hospital policy approved by the medical staff, but no later than 72 hours after the order was given.

c)         Members of the medical staff, house staff members, or allied health personnel with clinical privileges recommended by the hospital medical staff and granted by the hospital governing board shall give orders for medication and treatment only to the licensed, registered or certified professional persons who are authorized by law to administer or dispense the medication or treatment in the course of practicing their identified specific discipline.

d)         The medical directors of the laboratory, radiology, or other diagnostic services may respectively authorize the performance of diagnostic tests and procedures at the request of other than members of the medical staff in accordance with policies approved by the medical staff and governing board.

e)         The medical director of the physical therapy or rehabilitation department may authorize the provision of physical therapy or rehabilitation services or treatments at the request of other than members of the medical staff in accordance with policies approved by the medical staff and governing board.

(Source:  Amended at 48 Ill. Reg. 7321, effective May 3, 2024)