When should you fill out a Protocol Deviation form?

• A. When the provider believes administration would endanger the patient, a medication is not available, or a physician's orders are outside the protocol
• B. When the patient requests a change
• C. At the end of the shift
• D. If the patient is transported to a different facility

Answer: (A)

Filling out a Protocol Deviation form is for documenting when you must depart from the standing protocol because patient safety or practical issues require it. It covers situations where administering a medication would endanger the patient, when a needed medication isn’t available, or when a physician’s orders fall outside what the protocol allows. This creates an official record and allows medical control to review the decision, ensuring accountability and ongoing quality and safety.

If a patient simply requests a change, or if the situation is just ending a shift or transporting to another facility, those scenarios aren’t in themselves deviations from protocol and don’t automatically require a deviation form. Deviation forms are reserved for actual departures from protocol based on safety, availability, or outside orders.