{"ref":"GA-HH-ORD-01","title":"Physician Orders and Oral Orders","category":"Clinical tasks","summary":"Sets out who may give and receive orders for Agency patients and how oral orders are handled under Georgia’s rule: the nurse or therapist immediately records and signs the oral order, forwards the written order to the physician within five business days, and the physician’s countersignature is documented in the record within 30 days. Adds the federal rules for Medicare-certified agencies, including countersignature before billing.","inShort":["Give drugs and treatment only as the physician ordered.","Only RNs and licensed therapists take oral orders. Read the order back, then record and sign it right away.","The written order must go to the physician within five business days, and the signed order must be in the record within 30 days.","Add every new order to the plan of treatment and tell the patient and the team.","If an order is unclear or seems unsafe, do not carry it out until the physician clarifies it."],"primaryCitation":"Ga. Comp. R. & Regs. 111-8-31-.09(c)","citations":["Ga. Comp. R. & Regs. 111-8-31-.06(t)","Ga. Comp. R. & Regs. 111-8-31-.06(u)","Ga. Comp. R. & Regs. 111-8-31-.09(a)","Ga. Comp. R. & Regs. 111-8-31-.09(b)","Ga. Comp. R. & Regs. 111-8-31-.09(c)","Ga. Comp. R. & Regs. 111-8-31-.09(d)"],"federalCitations":["42 CFR §484.60(a)(3)","42 CFR §484.60(b)","42 CFR §484.60(d)","42 CFR §409.43(d)","42 CFR §484.110"],"surveyorAsks":["Show me the oral orders for this patient. When were they received, when were they sent to the physician, and when were they countersigned?","Who in your agency may accept an oral order?"],"forms":[{"ref":"GA-HH-ORD-01-A","title":"Oral Order Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (Ga. Comp. R. & Regs. 111-8-31-.09(c))","5. Who May Order Care","6. Who May Receive an Oral Order","7. Receiving and Recording an Oral Order","8. Forwarding and Countersignature","9. Tracking Unsigned Orders","10. Written, Faxed, and Electronic Orders","11. Carrying Out and Clarifying Orders","12. Responsibilities","13. Records and Compliance Monitoring","14. Staff Training","15. References","16. Related Policies and Forms","17. Approval","18. Revision History"],"version":"1.0","sample":false,"pack":"ga-hha","state":"Georgia","service":"Home health","guides":[{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}