Guideline for Doctors Issuing Permits Under Section 38a of the Nursing Act (50 of 1978)

Introduction
The permit to purchase, keep and dispense medication under section 22a of Act 101 does not make provision for the nurse to assess, diagnose, treat and prescribe for ailments encountered in a primary care context. Section 38a of the Nursing Act (50 of 1978) makes provision for nurses working in designated health care facilities to be authorised to assess, diagnose, prescribe and treat certain health conditions if a medical practitioner or pharmacist is not available. However, until recently, clinics in the private sector were not designated, and occupational health nurses were practising illegally. As an interim measure, recognising the crucial role that occupational health clinics play in the provision of primary and emergency care to employees who cannot afford medical aid, the Director-General: Department of Health has designated occupational health clinics under section 38a of the Nursing Act (50 of 1978). This interim concession allows the doctor in charge of the clinic to authorise the nurse to diagnose, prescribe medication and treat patients presenting to the clinic when the doctor is unavailable. This guideline sets out criteria to assist the medical practitioner in giving this authority.

•	The doctor must be familiar with the terms and conditions of the permit issued to the clinic under section 22A of  The Medicines and Related Substances Control Act (101 of 1965) and the requirements of section 38a of the Nursing Act (50 of 1978).
•	The doctor should assure himself/ herself that the nurse is competent to perform the tasks being authorised by the permit. This should be through appropriate training, qualification, by evaluation of past experience and by work under direct supervision for a period. A qualification does not necessarily guarantee competence. Qualifications should be accredited by the Nursing Council.
•	The nurse should not be asked to perform any task that is beyond his/her scope of practice or that he/ she is not competent to perform.
•	There should be a comprehensive set of treatment protocols relating to the management of all medical conditions likely to be encountered in the clinic. Suitable algorithms should be built into the protocols. There should be clear instructions on when to refer, what treatment the nurse can initiate, what treatment can be changed and the circumstances under which changes can occur. All such changes should be recorded in the patient’s file and countersigned at the earliest opportunity (not greater than one week as the case may be). The management of emergencies should be specifically addressed by these protocols and it is advisable that all nurses working in these clinics should have completed appropriate training (including regular refresher courses) in the management of common emergency situations. 
•	The treatment protocols should be supported by standing orders pertaining to the running of the clinic. These standing orders should list the conditions that the nurse is allowed to treat and should be reviewed and updated annually.
•	There should be open channels of communication between the doctor and nurse at all times and the doctor should be available for consultation during the hours that the occupational health clinic is open.
•	The doctor should be present in the clinic for the recommended number of hours according to the table below.
•	A formal drug control system should be implemented. Each prescription for schedule 3 or 4 drugs should be checked against the case notes and the drugs register and signed off in the drug register by the doctor.
•	Stock checks should be taken monthly and balanced against the drug register, signed by the nurse and countersigned by the doctor.
•	No charge may levied for medicines dispensed to employees under this permit.
•	Should there be more than one nurse required to perform these duties in the clinic, authority should be issued to each nurse individually.

It should always be remembered that the doctor remains the person ultimately responsible and accountable for the treatment of patients attending the clinic. As with doctors, nurses should be careful not to practise beyond their scope of practice and are responsible for their own act and omissions. They should not be coerced to practise beyond their competence.  Doctors should ensure that only medicines 
on the prescribed list (as issued by the Department of Health) are ordered and stocked by the clinic, unless written permission has been obtained to order additional medicines not on the list.

Number of Employees at site	Hours Dr should be present in the clinic per week	
1 – 500	1	
501 – 1000	2	
1001 – 1500	3	
1501 – 2000	4	
2000 – 3000	5	
3000+	Full time doctor	
(Ideally the time should be spread over the week)	
These are minimum guidelines and additional time may be necessary depending upon the risk profile of the industry.
2

Authority under section 38A of the Nursing Act (50 of 1978)
A copy of this authority should be faxed to the Department of Pharmaceutical Services Planning.

Fax no. (012) 312 0062

Name & Surname of Nurse: ____________________________________________________________

Clinic: ___________________________		Section 22A permit no: _______________

You are hereby authorised to diagnose and treat the conditions listed in the standing orders of the clinic according to the treatment protocols contained in the (name of book/ manual) subject to the limitations imposed by the medicines list of the dispensing permit.

You are to maintain legible, comprehensive clinical notes in the patient file and to complete the drug register required under the permit issued section 22A of Act 101.

Name & Surname of Doctor: __________________________________________________________

Signature: ______________________	Qualifications: ________________________

HPCSA No.	______________

Postal Address: _____________________________________________________________________

Tel: (       ) __________________________   Fax: (        )____________________________________

E-Mail : __________________________________________________________________________

Date: ____/_____/______