{"ref":"NC-HH-ORD-01","title":"Physician and Practitioner Orders, Verbal Orders, and Countersignature","category":"Clinical tasks","summary":"Requires every drug, treatment and service to be given only on the order of a physician or other authorized practitioner; sets who may take a verbal order, how it is read back, recorded, signed, dated and timed; requires countersignature within the Agency’s time frame of 14 days, never more than the 60 days North Carolina allows and always before a Medicare claim is billed; and sets how orders are tracked, clarified and kept.","inShort":["We give drugs, treatments and services only as a physician or other authorized practitioner has ordered.","Only registered nurses, licensed practical nurses (for drugs and treatments) and therapists (for their own discipline) may take a verbal order.","Write the order down, read it back, and record the date, the time and your signature.","Get every verbal order signed by the practitioner within 14 days, never more than 60 days, and before Medicare is billed.","If an order is unclear, unsafe or conflicts with another order, do not carry it out until the practitioner clarifies it."],"primaryCitation":"10A NCAC 13J .1302","citations":["10A NCAC 13J .0901","10A NCAC 13J .1202(a)","10A NCAC 13J .1302","10A NCAC 13J .1402(b)","NC Medicaid Clinical Coverage Policy 3A"],"federalCitations":["42 CFR §484.60(a)","42 CFR §484.60(b)","42 CFR §484.60(d)","42 CFR §409.43","42 CFR §424.516(f)","42 CFR §484.110(b)"],"surveyorAsks":["Who in your agency may take a verbal order? Show me where that is written.","Show me this verbal order: who took it, when, and when the physician signed it."],"forms":[{"ref":"NC-HH-ORD-01-A","title":"Verbal Order Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (10A NCAC 13J .1302; 42 CFR §484.60(b))","5. Who May Give an Order","6. Written Orders","7. Who May Take a Verbal Order","8. Taking and Recording a Verbal Order","9. Getting Verbal Orders Signed","10. Orders From More Than One Practitioner, and Questioning Orders","11. Orders for In-Home Aide Services and Supplies","12. Keeping Orders","13. Responsibilities","14. Records and Compliance Monitoring","15. Staff Training","16. References","17. Related Policies and Forms","18. Approval","19. Revision History"],"version":"1.0","sample":false,"pack":"nc-hha","state":"North Carolina","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}}