Protocols and Standing Orders in Med Spas

As med spas continue to expand across the country, regulators and plaintiffs’ attorneys alike are focusing on core central issue: who is practicing medicine, under what authority, and pursuant to what documented framework? Two foundational compliance tools - clinical protocols and standing orders - are essential to answering those questions. While often referenced together, protocols and standing orders serve distinct legal and operational purposes. Understanding the difference is critical for med spa owners and medical directors.

I. Why Protocols and Standing Orders Matter

Med spas operate in a hybrid space between aesthetics and medicine. Services such as:

• Neurotoxin and dermal filler injections

• Laser and light-based treatments

• Microneedling and RF procedures

• PRP and regenerative therapies

• IV therapy and wellness injections

legally constitute the practice of medicine. In Texas, these procedures generally must be performed by a physician or delegated appropriately under statutory supervision rules.

Without proper protocols and standing orders, a med spa risks:

• Unlawful practice of medicine allegations

• Corporate practice of medicine violations

• Medical board discipline

• Nursing board investigations

• Increased malpractice exposure

• Insurance coverage denials

II. What Are Clinical Protocols?

Clinical protocols are detailed, written policies that govern how specific medical procedures are performed within the practice.

They typically include:

• Patient eligibility criteria

• Contraindications

• Required assessments

• Informed consent standards

• Treatment steps

• Dosing ranges

• Emergency procedures

• Post-care instructions

• Documentation requirements

• When to consult or escalate to a physician

Protocols function as the clinical roadmap for the practice. They demonstrate that treatments are delivered pursuant to medical judgment rather than ad hoc decision-making.

Legal Purpose of Protocols

Protocols help establish:

1. That the medical director has exercised appropriate oversight.

2. That delegated providers are operating within defined scope.

3. That care is standardized and defensible.

4. That adverse outcomes are not the result of systemic negligence.

In litigation, protocols often become central exhibits. The question will not simply be “Was there a protocol?” but “Was it followed?”.

III. What Are Standing Orders?

Standing orders are written physician authorizations allowing qualified personnel to perform specific medical acts without obtaining patient-specific orders each time.

In med spas, standing orders may authorize:

• Administration of neurotoxins within specified dosing ranges

• Dermal filler injections under defined parameters

• Initiation of IV fluids and vitamins

• Use of specific laser modalities

• Emergency medication administration (e.g., epinephrine, hyaluronidase)

Standing orders are not blanket permission slips. They must:

• Be signed and dated by the supervising physician

• Identify authorized personnel

• Specify allowable treatments

• Include required assessment criteria

• Outline supervision requirements

In states like Texas, delegation must comply with Medical Practice Act requirements and Board of Nursing rules when nurses are involved.

IV. Protocols vs. Standing Orders: Key Differences

Clinical Protocols:

·      Broad operational framework

·      Describe how care is delivered

·      Often multi-page treatment guides

·      Focus on safety and consistency

·      Used for risk management

Standing Orders:

·      Authorize who may deliver care

·      Specific delegated authority

·      Typically more concise authorizations

·      Focus on delegation legality

·      Used for regulatory compliance

Both are necessary. One without the other creates compliance gaps.

V. Common Compliance Failures in Med Spas

1. Generic, Non-Customized Documents: Using downloadable templates that do not reflect state law or actual practice operations.

2. “Paper-Only” Medical Directors: A signed standing order without meaningful oversight may trigger corporate practice violations.

3. No Treatment-Specific Protocols: Having a general “injectables protocol” without differentiating between neurotoxins and fillers.

4. Failure to Update: Protocols must evolve with new devices, products, and expanded services.

5. Improper Delegation: Authorizing individuals to perform procedures outside their licensure scope.

VI. Special Considerations for Texas Med Spas

Given the rise of wellness services in Texas med spas, additional scrutiny applies to:

• IV therapy models

• Telemedicine evaluations

• Off-site physician supervision

• Ownership structures

• Independent contractor injector models

Texas requires careful alignment between the Medical Practice Act, Board of Nursing rules, and corporate structure. Standing orders cannot cure an unlawful ownership arrangement.

VII. Risk Management Best Practices

To strengthen compliance and reduce liability exposure, med spas should:

1. Conduct a Legal Audit: Review delegation structure, supervision model, and ownership compliance.

2. Customize Treatment-Specific Protocols: Each modality should have its own written clinical protocol.

3. Align With Licensure Scope: Confirm that each provider’s license permits the delegated activity.

4. Define Supervision Levels: Clarify when direct, indirect, or general supervision is required.

5. Require Annual Review: Medical directors should re-sign and update standing orders annually.

6. Document Oversight: Maintain records of chart reviews, training sessions, and quality assurance meetings.

7. Implement Emergency Protocols: Anaphylaxis kits, hyaluronidase availability, and crash cart readiness should be documented and trained on.

VIII. The Litigation Perspective

In aesthetic malpractice litigation, plaintiff attorneys routinely ask:

• Who performed the procedure?

• Under what authority?

• Where is the signed standing order?

• Was the patient properly evaluated by a physician?

• Did the injector follow the written protocol?

• What supervision occurred?

The absence of clear documentation often converts a defensible complication into a costly settlement.

Conclusion on Protocols and Standing Orders in Med Spas

Protocols and standing orders are not mere administrative paperwork; they are the structural backbone of a compliant med spa. As regulatory scrutiny intensifies and AI, telehealth, and wellness services expand the treatment landscape, clear delegation frameworks become even more critical.

For med spas seeking sustainable growth, investing in properly drafted protocols and legally sound standing orders is not optional; it is foundational risk management.

Feel free to reach out if you need more specific information or further clarification.

Weitz Morgan is a leading law firm in Texas in providing comprehensive advice and guidance to med spas. With a deep understanding of the unique challenges and complexities faced by this rapidly growing industry, our team of experienced attorneys is dedicated to helping med spas navigate the legal landscape successfully.

We recognize that med spas operate at the intersection of healthcare and beauty, which necessitates a multifaceted approach to representation. Our firm offers a range of services, including a flat-fee med spa formation package and an outside general counsel subscription, tailored to meet the specific needs of med spas, ensuring compliance, mitigating risks, protecting licenses, and fostering a legally sound business environment.