Example of internal medicine policy and procedure modelPOLICY NUMBER: [insert policy number]POLICY TITLE: Diabetes Mellitus Standing Orders

PURPOSE: To optimize the care of patients with diabetes by improving workflow processes through the implementation of standing orders.

PRACTICES: 1. [insert eligible health care provider] may order laboratory tests based on the protocol outlined below.2. All labs should be drawn at least one week prior to the patient’s annual visit.3. Any clarification regarding the protocol should be discussed with the physician.

PROTOCOL:1. Hemoglobin A1c

a. Above target goal: draw every 3 monthsb. At goal: draw every 6 months

2. Basic metabolic panela. Patient is on an ACE inhibitor or diuretic or has CKD: draw every 6 monthsb. Patient not on an ACE inhibitor or diuretic: draw every 12 months

3. Lipid profilea. Draw every 12 months

4. Ophthalmologist/optometrist referral for dilated eye exam every 12 months5. Monofilament foot exam every 12 months6. Urine sample for proteinuria every 12 months (albumin/creatinine ration)7. Physical therapy as needed if deconditioned or has poor balance8. Diabetes education referral every year9. Immunizations

a. Follow clinical practice guidelines for the Advisory Committee on Immunization Practices (ACIP) Adult Immunization Schedule

b. Influenza vaccine annuallyc. PPSV-23 (Pneumovax®23)

i. No patient should receive more than 3 doses of PPSV-23 in a lifetimeii. Prior to age 65: patient should receive one doseiii. 65 years and older: patient should receive one dose and fulfill the following requirements:

1. Must be at least 5 years since last Pneumovax®23 administration2. Must be at least 1 year since last Prevnar13® administration

d. PCV-13 (Prevnar13®)i. 65 years and older: patient should receive 1 dose after the age of 65 (must be at least 1 year

after administration of a Pneumovax®23 vaccine)e. Hepatitis B vaccine:

i. Less than 60 years of age: patient should receive a 3-dose series (0, 1, and 6 months)

Disclaimer: Please note that clinical guidelines change frequently and this document is meant as an example only. The standing order can be modified so you can update it based on your patient population and current guidelines. This content is provided for informational purposes only and is not intended as medical advice, or as a substitute for the medical advice of a physician. Consult appropriately qualified legal counsel regarding applicability of or compliance with federal and state laws and regulations.

Source: AMA. Practice transformation series: improve care for patients with type 2 diabetes. 2017.

Copyright 2017 American Medical Association. All rights reserved. 1