Drugs may be dispensed from the institutional pharmacy only in response to medication orders issued by prescribers who have been authorized to do so by law and by the governing body of the institution. Documentation. Institutional Medication Protocols. The pharmacist may dispense, or make available, drugs for an approved institutional medication protocol if conditions designated by the institution are met. The director of pharmacy or designee shall assist in establishing institutional policies and procedures governing the development of order-sets for each individual situation for which institutional medication protocol orders exist. The appropriate committee of the institution shall approve any order-sets before the pharmacist may provide the medications based on the institutional medication protocol. A pharmacist may provide medications based on orders which do not contain unapproved abbreviations as published by the appropriate committee of the institutional facility. The director of pharmacy or designee shall ensure that authorized personnel have access to patient information necessary for drug monitoring including the patient's: Sex; Age; Weight; Height; Diagnosis; Medication and food allergies; Pregnancy and lactation status; Vaccination status; and Name.